ESLD Flashcards
MASLD/MASH (Metabolic dysfunction associated steatotic liver disease/steatohepatitis)
Clinical presentation :
Sx’s?
Labs?
Liver biopsy?
Any drugs yet? What can be ways pt’s can combat this?
Mostly asx’s !
+/- Fatigue and Upper abd pain
-AST/ALT can be normal or abnormal
- Steatosis, lobular inflammation, ballooning
No drugs approved. Weight loss, diet and exercise
Comorbid conditions associated with MASLD?
Obesity, T2DM, HTN, DLD, Obstructive sleep apnea, CVD (Important cause of death in MASLD pt’s) , CKD
NALFD (MASLD) in Lean Individuals
-Occurance in pt’s with which BMI?
-More common in pt’s of which heritage?
-What would be appropriate for these pt’s?
<25 or <23 in asians
hispanic, asian
weight loss not appropriate but dietary modifications and exercise!
Lifestyle Modifications For management of NAFLD (MASLD) GENERAL
Weight loss of ?
identify?
Get ___
Maintain ___
Specifically incorporate?
Specifically avoid?
> 5-10% of initial body weight
-psychological barriers to lifestyle change and physical barriers to lifestyle change
-sufficient sleep
-weight loss
Water and zero calorie bevs in place of sugary beverages , more active lifestyle, portion controll, limit alc, coffee, use stairs, wear pedometer
late night eating, sugary beverages and deserts
DIET
restriction of calorie intake by?
Carb amount?
Replace calories with ?
Avoid ?
what should pt’s specifically avoid?
500-1000 kcal daily (1200-1500 kcal daily if ur <115 kg, 1500-1800 kcal daily if ur >115kg)
low carb diet (<40-45%) (veggies 3-5 servings, fruits 2-4 servings)
PUFA, MUFA (EVOO 60 mL daily, nuts, avocado, olives, oily fish like salmon and tuna)
Trans fat, limit saturated fats to 7-10% (incorp olive oil or olives)
High calorie foods, high sugar bevs, simple carbs and high fructose corn syrup, herbal supps and non prescribed vitamins)
EXERCISE
Increase physical activity as tolerated based on medical conditions
Describe some incorporations and what to avoid
Cardiovascular training 5x per week , resistance training >/= 2x per week
150-300 min weekly at mod intensity or 75-100 min weekly at vigorous intensity
AVOID sedentary lifestyle
What’s the cornerstone?
NO FDA approved tx
What can be used for T2D/obseity in pt’s with NASH or MASH?
WHat can be considered for NASH pt’s with T2d ?
DIET AND EXERCISE
Semaglutide
Pioglitazone
CIRRHOSIS : Child Turcotte Pugh Classification
Clinical and Lab criteria?
State the diff between Class A and Class C
Encephalopathy, ascites, bilirubin, albumin, prothrombin time
Class A = 5-6 pts, 5-10% chance of dying in next five yrs! relatively stable
Class C = 10-15 pts , 75% mortality in the next year
Compensated Vs DECompensated Cirrhosis
Compensated ? Sx’s? Death at 1 yr?
Decompensated sx’s? death at 1 yr?
Comp : asx’s +/- varices
1-3%
Stage 1 and 2
Decomp : Development of jaundice, ascites, variceal hemmorhage, HE, or CTP score 10-15 class C
20%-57%
Stage 3 and 4
Overall goals to Manage Cirrhosis/ESLD
-protect the __ from harm
-Discontinue ____
Monitor ____
Avoid _____
Maintain vigilence for comps of cirrhosis
screen for ____
Screen for ____ every ___
Refer for ___
liver
harmful meds
BP
alc,nsaids, herbal meds, raw shellfish
esoph varices
HCC, 6 months
liver transplant if needed
ASCITES
-Most common comp of cirrhosis
-Clinically evident when ???
Goals of therapy
Decr __,___,____
Prevent complications such as?
Weight loss of ?
Urine output should exceed fluid intake by ____
Considerations
How should u remove the fluid? What should u be careful of when u over diurese?
> 1500 mL fluid has accumulated
abd discomfort, back pain ,difficulty ambulating
respiratory distress, spont bacterial peritonitis, hernias, pleural effusions
0.5-1kg/day = 0.5-1L/day
300-1000 mL/day
Gradual and cautious removal of fluid
-Acid base imbalance, electrolyte imbalance (HYPOkalemia), intravascular volume depletion
ASCITES : Diuretic Therapy
What drug combo and dose?
Can incr simultaneously every ?
Maintain a ___ ratio
max doses?
furosemide added to ?
Spironolactone 100 mg PO daily + Furosemide 40 mg PO daily
3-5 days to achieve adequate diuresis and maintain normal Serum K
100:40 ratio
max = 400 mg spiro, 160 mg furo
minimize risk of hyperkalemia and enhance diuresis
Refractory ascites
-Unresponsive to sodium restriction max dose spiro+furo
50% mortality in six months
-recurs rapidly after paracentesis
WHat’s the alt therapy ?
Midodrine 7.5 mg PO TID
Paracentesis
-Indicated in ?
Risk of?
What’s the range of fluid u can remove?
What’s given for large volume?
REFRACTORY ascites
-Infection or hypovolemic shock
1L to 10L
Albumin (given for >5L)
ASCITES NON PHARM
Protein ?
Sodium restriction ?
Fluid restriction ?
Nsaids?
Ace or arbs?
Alcohol?
1-1.5 gm/kg/day
2g/day
only if Na<120
avoid!
avoid
DC
ASCITES MONITORING
Therapeutic (5)
If their urine Na: K ratio is <1 what does that suggest and what do u have to do?
Toxic Monitoring Parameters with Spiro/Furo (5)
body weight, abdominal girth, fluid intake, urine output, urine Na, K.
suggest high intrinsic aldosterone activity –> higher dose of spiro
Hyponatremia, Hyperkalemia, Metabolic alkalosis, hypokalemia , gynecomastia (spiro)
Esoph Varices
-Dilated submucosal veins in esoph
-medical emerg if they bleed –> death
-Incidence in Child’s a vs Child’s C pts?
-If ur portal venous pressure is greater than ___ that incr ur risk for variceal hemmorahge
-emphases on ___ of bleeding
-Diagnosed by ___
Child’s A : 40%, CHilds C : 85%
12 mmHg
PREVENTION
Endocscopy
Esoph Varices TX
Goals of TX for acute variceal bleed?
What’s the drug (Vasoconstrictive agent), what’s the dose, and what’s the duration?
AE”s?
Volume resuscitation, acute tx of bleeding, prevention of occuring again
Octreotide : Initial IV bolus of 50 mcg (Can be repeated in first hr if ongoing bleeding)
-continuous IV infusion of 50 microg/hr
-2-5 days
Diarrhea, abd pain, hyperglycemia, hypoglycemia, constipation
ESOPH VARICES PRIMARY PROPHYLAXIS
-Prevention of an initial episode of bleeding
-Indicated for pt’s ???
What drugs do u use ???
What does it do?
action on Beta 1 R’s and Beta 2 R’s ?
w/varices that have not bled and CHild’s B or C
Non selective Beta blockers , (Nadolol, Carvedilol, Propanolol)
-Decr portal pressure by decr portal venous blood flow –> B1 decr cardiac output and B2 decr splanchnic blood flow
ESOPH Varices Primary Prophylaxis
Dose the 3 beta blockers
Propanolol
Nadolol
Carvedilol
20-40 mg po BID . Adjust q2-3 days until tx goal . max dose 320 mg/day in pt’s w/o ascites. If ascites, 160 mg/day
20-40 mg po once daily. Same adjustment
Max dose 160 mg/day without ascites, 80 mg/day with
6.25 mg once daily. After 3 days incr 6.5 BID. Max dose 12.5 mg/day
Esoph varices : Prevention of Recurrent varices
Which drugs?
+
EVL how often ?
Propanolol and Nadolol is used NO CARVEDILOL
EVL Q1-4 wks until eradication of varices
Hepatic Encephalopathy –> Metab disorder of CNS
-Clinical features? (3)
Precipitating Factors (Excess N, Fluid and electrolyte abnorms, drug induced cns depression)
Altered mental status, asterixis or flapping tremor, fetor hepaticus (Sweet musty pungent odor of breath)
N : bleeding, peptic ulcer, renal failure, infection , constipation
F : Hypokalemia, alkalosis , hypovolemia, excess diarrhea, vomiting
D : Sedatives, tranquilizers, narcotics
HE Therapy : GOALS
What are the 4 goals
What is the drug used? Dosing (ACUTE VS CHRONIC )
DOSING FOR ENEMA
What can u dilute it in?
AE”s?
- Provide supportive care
- Identify and remove precip factors
- Reduce nitrogenous load from GI tract
- Assess need for long term therapy
Lactulose syrup or enema
ACUTE : 30-45 mL po qhour until evacuation; titrate to 2-4 soft bowel movements/day
Chronic : 30-45 mL po daily-qid ; titrate to 3 soft bowel movements/day
Enema : Lactulose 300 mL in 700 mL water PR ; retain for 30-60 mins
Fruit juice, carb bevs, water
Diarrhea, abdom cramping, flatulence
HE : Rifaximin
What is it?
Dose?
Better __ and ___ to lactulose
Often given together with ?
AE’s
Antibiotic with low systemic avail
400 mg PO TID or 550 mg PO BID
tolerability, ~ equiv efficacy
lactulose for improved efficacy
flatulence, abd pain , angioedema which is rare
DILI
Leading cause of ?
Acute liver failure requiring liver transplant in USA
ACUTE HEPATIC NECROSIS
Example drugs? (3)
Acute, toxic injury to liver (DIRECT) with what kind of onset?
Marked elevations in ?
Early signs of ?
Jaundice?
Usually ____
Time to onset is short about ___
Tylenol, niacin, mtx , aspirin
Sudden, precipitous onset.
Serum Aminotransferases (>20 ULN) . ALT will be marked elevation. Mild Alkp and bilirubin
hepatic failure
minimal or no jaundice
dose dependent (usually OD)
1-14 days
Acute Hepatitis DILI
Drugs?
Clinical course resembles?
ALT? Sx’s? Bilirubin?
Time to onset?
Type of liver injury?
Death rate?
Isoniazid, diclofenac ,green tea and herbals
viral hep
ALT >20x ULN, fatigue, BILI > 2.5 mg/dL
2-24 weeks
Idiosyncratic or indirect
High death rate
Cholestatic Hep DILI (Idiosyncratic)
Drugs?
Characterized by ?
Liver enzyme pattern predom by increases in ?
Time of onset?
Less likely to lead to acute liver failure or death (vs acute) however prolonged can lead to ?
Sulfonylureas, rifampin, penicillins, cephalosporins, methimazole , augmentin ,cefazolin
Cholestasis with sx’s of fatigue, pruritis, dark urine, jaundice
AlkP (3x ULN), bilirub >2.5 mg/dL
2-12 weeks, may occur up to 1 yr after starting meds
vanishing bile duct syndrome and or chorn liver injury, cirrhosis
Guidelines for Use of Drugs in Liver Disease
Conservative use of drugs
Avoid which kinda drugs?
hepatically elim drugs;drugs with active metabs, sedating meds, hepatotoxic agents, nephrotoxic agents , agents that precipitate bleeding
avoid IM injections
