Liver Disease Flashcards
Describe the liver.
What are some of the major functions of the liver?
Liver is one of largest organs in body
- 1.5kg in adult
- 2 lobes
- blood supply by portal vein (rich with digestion end products) and hepatic vein (oxygen rich).
- bile acid production
- CHO metabolism (gluconeogenesis, glycogenesis, glycogenolysis)
- protein and lipid metabolism
- vitamin store
- detoxification of alcohol/drugs
- synthesis of haem.
What is meant by the term ‘liver disease’.
- types of liver disease
- prevalence
- classification (acute vs chronic)
- which associated with nutritional status?
Liver disease is an umbrella term for wide range of liver disorders:
- hepatocellular carcinoma (liver cancer)
- cirrhosis
- NAFLD
- alcoholic fatty liver disease
- ASH/NASH
- hepatitis
Prevalence:
UK - 3rd leading cause of premature death.
Classification:
Acute:
AFL - acute liver failure
deranged liver blood results without underlying disease
e.g., hepatitis, drug overdose
Chronic:
develops over long period of time
many aetiologies causing hepatocellular damage (inflammation, scarring, infection)
Liver diseases strongly associated with nutritional status:
- ALF
- ASH/NASH
- Alcoholic fatty liver disease
- Non-alcoholic fatty liver disease
- Liver Tx
Describe the progression of liver disease.
healthy liver
liver fibrosis
liver cirrhosis
if causative agent is removed when liver is fibrotic liver disease can be reversible.
liver cirrhosis is irreversible end stage liver disease.
What is the difference between compensated and decompensated liver disease?
Compensated: nil symptoms of liver disease as liver able to function normally.
Decompensated: symptoms present e.g., ascites, jaundice, hepatic encephalopathy.
The liver can shift between compensated and decompensated status during progression of liver disease.
Describe alcoholic liver disease
- risk factors
In EU, alcohol is main cause of liver disease.
alcoholic fatty liver –> alcoholic hepatitis –> fibrosis –> cirrhosis
risk factors:
- high alcohol intake over long duration.
Describe non alcoholic liver disease
- risk factors
NAFLD:
liver fat accumulation (>5% hepatocytes) without excessive alcohol intake or other liver disease.
non-alcoholic fatty liver –> fibrosis –> cirrhosis
risk factors:
- waist circumference (men: 102cm, women: 88cm)
- hyperlipidaemia
- metabolic syndrome
- T2D/insulin resistance (twin cycle)
How can liver disease be prevented?
most major causes of liver disease are preventable:
- alcohol
- waist circumference
- metabolic syndrome
Diet and lifestyle modifications.
What are the causes of malnutrition in liver disease?
- significance of malnutrition in liver disease
- causes of malnutrition in liver disease
Protein Energy Malnutrition (PEM) exists in 80-100% patients with liver disease.
30-70% cirrhotic patients have sarcopenia. Can occur with fat loss (cachexia) or excessive fat (sarcopenic obesity).
Changes in metabolism
- decreased glycogen store
- decreased glycogenolysis
- fat/protein used for energy
Reduced intake
- anorexia
- early satiety
- disrupted sleep
- encephalopathy
- nausea/vomiting
- altered taste - Zn/Mg deficiency
- alcohol replaces meals
Poor quality diet
Malabsoprtion
Increased protein losses
Micronutrient deficiency
- Fat sol vitamins (A,D,E,K)
- Zinc
- Magnesium
Steatorrhea
- fat lost in stools
Describe nutritional assessment for patients with liver disease.
- screening tools
- nutritional assessment
screening tools:
MUST
- ensure dry weight used
(Wet weight - estimated weight of ascites = dry weight)
Royal Free Hospital Global Assessment (RFH-GA)
- developed and validated for use in cirrhotic patients
Anthropometry:
- DRY WEIGHT!! (weight history also useful)
- MUAC/TSF to assess muscle wasting as this area rarely affected by ascites)
- HGS: functional measure of muscle status
- waist circumference (men: 102cm, women: 88cm)
Dietary:
- evidence of malabsoprtion
- alcohol intake
- calculate requirements
Biochemical:
- albumin
- bilirubin
- eGFR/creatinine
Describe the recommendations for nutritional management of liver disease (cirrhotic)
- eating pattern
- use of ONS
- use of enteral feed
- vitamin/minerals
EATING PATTERN:
4-7 small meals + CHO (50g) snack in evening
- avoid fasting longer than 2-3 hours
examples of 50g CHO snack:
- 5 plain biscuits
- 2.5 thick slice bread
- 40g cereal + milk
Opt for high energy/high protein foods to help meet requirements.
USE OF ONS:
use of ONS is appropriate if oral intake insufficient.
opt for high energy low volume to help with fluid restriction, early satiety, nausea/vomiting.
USE OF ENTERAL FEED:
- when oral diet cannot be tolerated
- when pt dies not have safe swallow
- when anthropometrics deteriorating
Feed overnight to allow for oral diet during day.
VITAMINS/MINERALS:
- Ca & Vit D supplement
- B Vitamins (especially thiamine) for alcoholic liver disease
- fat sol vitamins prescribed on case-by-case basis
protein and energy requirements associated with lean body mass - dry weight should be used or adjustments made for fluid overload/ascites.
ENERGY:
PENG details REE values for specific liver diseases
PENG: 30-35kcal/kg/day (general)
ESPEN: 35-40kcal/kg/day
PROTEIN:
1.2 (non-malnouirished) - 1.5 (malnourished) kcal/kg/day
up to 2g/kcal/day in severe sarcopenia/cachexia
Adjustment for obesity:
BMI > 30: 75% requirement
BMI > 50: 65% requirement
Describe nutritional management of non-cirrhotic NAFLD:
nutritional assessment:
Anthropometry
- BMI
- waist circumference
Clinical
- stage of liver disease
- symptoms e.g., ascites
Encourage exercise
- 30 mins/day
Weight management
- aim BMI <25
- 10% reduction in baseline in 6m-1yr
- weight loss < 1kg/week (too quick can worsen liver function)
General healthy eating advice
- eatwell guide
- other specific diets e.g., cardioprotective, diabetic diet
Alcohol
- complete abstinence
- < 14 units/week
When is sodium/fluid restriction advised?
Sodium restriction:
- for patients with ascites
no-added sodium diet recommended
approx 4.5-6g salt per day
Fluid restriction:
- when patients hyponatraemic
- if patient drinking excessively with rapidly accumulating ascites
