Liver disease

Question 1

List some common causes of liver disease mentioned in the content.

Answer 1

Common causes of liver disease include alcohol-related liver disease, viral hepatitis, metabolic dysfunction-associated liver disease, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and metabolic disorders like Wilson’s disease.

Question 2

Explain the difference between compensated and decompensated liver disease.

Answer 2

Compensated liver disease is asymptomatic, while decompensated liver disease presents symptoms like jaundice, hepatic encephalopathy, portal hypertension, variceal bleeds, and ascites. Decompensated liver disease is end-stage and irreversible.

Question 3

Name two important clinical factors relating to decompensated liver disease

Answer 3

• bilirubin will be high in decompensated liver disease
• NO EVIDENCE that low protein diet supports with hepatic encephalopathy

Question 4

How does malnutrition impact patients with liver disease?

Answer 4

Malnutrition is common in liver disease, affecting up to 80% of patients with decompensated cirrhosis. It leads to increased complications, muscle mass loss, susceptibility to infections, hepatic encephalopathy, and lower survival rates in transplant patients.

Question 5

Describe the prevalence of malnutrition in liver disease.

Answer 5

Malnutrition is prevalent in about 20% of patients with compensated cirrhosis and over 80% in those with decompensated cirrhosis. It affects protein, carbohydrate, and fat metabolism, leading to increased nutritional requirements and various complications. Nutritional requirements for calories and protein are increased in liver disease by up to 60%

Question 6

Describe the definition of sarcopenia and its implications on muscle mass, strength, and physical function.

Answer 6

Sarcopenia refers to the loss of muscle mass, strength, and physical function. It can lead to decreased mobility, increased risk of falls, and overall reduced quality of life.

Question 7

How does sarcopenia manifest in liver disease in terms of inadequate dietary intake? 6

Answer 7

inadequate dietary intake

• low appetite
• nausea
• early satiety
• active alcoholism
• zinc deficiency causing taste alterations
• dietary restrictions due to inaccurate nutritional advice

Question 8

How does sarcopenia manifest in liver disease in terms of metabolic disturbances? 2

Answer 8

• increased gluconeogenesis: in healthy liver, carb is stored for 72 hours. Cirrhotic liver: 10-12 hrs, lack of glycogen leads to extra protein breakdown. Brain’s only energy substrate is glucose so body will prioritise fat and protein breakdown over glycogen if stores are low
• hypermetabolic state

Question 9

How does sarcopenia manifest in liver disease in terms of malabsorption? (5)

Answer 9

• portosystemic shunting
• Chronic pancreatitis
• Intraluminal bile acid deficiency
• Small intestinal bacterial overgrowth
• only time altered diet used for malabsorption is if bilirubin is extremely high

Question 10

Define the importance of nutritional assessment in decompensated liver disease, considering factors like ascites and dietary intake.

Answer 10

Nutritional assessment is crucial in decompensated liver disease, but MUST may be inaccurate due to ascites falsely inflating weight.

Need to account for ascites
Mild:> 2.2kg
Moderate: >6kg
Severe: >14kg

Check medical notes for ascites drainage to estimate DW.

peripheral oedema:
Mild: 1kg
Moderate: 5kg
Severe: 10kg

Question 11

Describe the significance of anthropometry in assessing sarcopenia, including measurements like TSF, MAMC, and MUAC.

Answer 11

Anthropometry plays a key role in assessing sarcopenia by measuring factors like TSF (indicator of fat mass), MAMC (predictor of mortality after liver transplant), and MUAC (reflects both fat and fat-free mass).

Question 12

How is handgrip dynamometry used in nutritional assessment, and why is it considered a sensitive indicator of malnutrition?

Answer 12

Handgrip dynamometry is utilized to measure muscle function and malnutrition, being reproducible and sensitive. It is recommended to repeat weekly to monitor changes accurately.

Question 13

What is the liver frailty index?

Answer 13

• robust way of determining anthropometry in liver disease patients
• 3 groups: robust, pre frail, and frail
• uses hand grip, balance, and sit to stand
• validated tool to predict poor prognosis in pre transplant/poor recovery post transplant

Question 14

Explain the various assessment methods for sarcopenia, including CT scans and frailty scores, and their implications on predicting adverse outcomes.

Answer 14

Assessment methods for sarcopenia include CT scans (gold standard), frailty scores (predictive of adverse outcomes), and tests like sit-to-stand and handgrip dynamometry. Frailty can delay transplants for nutritional support.

Question 15

Describe the concept of sarcopenic obesity and its implications on nutritional status.

Answer 15

Sarcopenic obesity refers to the simultaneous loss of skeletal muscle mass and gain of adipose tissue. This condition can lead to malnutrition despite the presence of obesity. It is often overlooked but can have significant impacts, such as post-transplant weight gain due to increased adipose tissue and muscle loss.

Question 16

How is nutritional requirements estimated for liver patients according to ESPEN guidelines?

Answer 16

ESPEN guidelines recommend energy intake of 25-40 kcal/kg based on the patient’s condition. For protein, the recommendation is 1.2-1.5g/kg. In cirrhosis, energy intake is 22 kcal/kg/day with 1.2-1.5g/kg protein. Post-liver transplant, energy intake is 23 kcal/kg/day with 1.2-1.5g/kg protein.

Question 17

Define the goals of nutritional support in healthcare settings. 4

Answer 17

The goals of nutritional support include

• improving nutritional status,
• maintaining or improving lean body mass,
• minimizing fluid retention
• reducing morbidity and mortality associated with malnutrition.

Question 18

What are some key strategies for oral nutrition support in patients with malnutrition?

Answer 18

Key strategies for oral nutrition support include consuming a 50g carbohydrate-rich bedtime snack to improve nitrogen balance, having regular meals and snacks to reduce fasting gluconeogenesis, ensuring moderate to high protein intake even in hepatic encephalopathy, and avoiding skipping meals to maintain adequate nutrition.

Question 19

What are the dietary recommendations for managing ascites in patients requiring nutritional support?

Answer 19

For patients with ascites, it is advised to avoid adding salt to meals and use a small pinch in cooking. They should steer clear of low-nutrient foods high in salt. Additionally, maintaining a balanced diet and monitoring fluid intake are crucial in managing ascites effectively.

Question 20

Describe examples of 50g carbohydrate snacks suitable for patients requiring nutritional support.

Answer 20

Examples of 50g carbohydrate snacks include 2 slices of toast with 300ml milk, 1 juice-based supplement, 5 plain or chocolate biscuits, a bowl of cereal with fruit, 1 milk-based supplement with a biscuit, fruit cake with a hot drink, or a tea cake with a large glass of milk. These snacks provide essential energy and nutrients.

Question 21

Describe the EN recommendations for liver disease with the citation.

Answer 21

Low threshold for enteral feeding.

Via NG and NJ feeding. NG 1st line. NJ for poor tolerance

Gastrostomy and jejunostomy contraindicated due to varices, ascites, raised INR levels and risk of bleeding

Plauth et al 2006

Question 22

How does MAFLD differ from AFLD in terms of diagnostic criteria and common causes?

Answer 22

MAFLD requires hepatic steatosis plus overweight/obesity, type 2 diabetes, or metabolic dysregulation. It is the most common liver disease. Lifestyle modifications like weight loss, diet changes, and physical activity are key. Omega-3, vitamin E, and coffee are beneficial.

Question 23

Define the role of parenteral nutrition in the management of liver disease according to Plauth et al 2009.

Answer 23

Parenteral nutrition is used when enteral routes are not tolerated. It carries infection risks and can affect liver function tests. Plauth et al 2009 recommends close monitoring and reserves parenteral nutrition for specific cases.

Question 24

What are the dietary considerations for patients with MAFLD besides lifestyle modifications?

Answer 24

In addition to lifestyle changes, MAFLD patients can benefit from omega-3 fatty acids, vitamin E, and moderate coffee consumption. These elements have shown protective effects against liver disease, but caution is advised due to potential risks.

Question 25

Describe the importance of early intervention in managing malnutrition and sarcopenia in chronic liver disease.

Answer 25

Early intervention is crucial due to the multifactorial causes of malnutrition and sarcopenia in liver disease. Factors like early satiety and malabsorption contribute. Unnecessary dietary restrictions should be avoided, and weight loss is not recommended for cirrhotic patients. Close monitoring is emphasized.

Question 26

Describe the key recommendations from the American Association for the Study of Liver Diseases regardingnutrition, frailty, and sarcopenia in patients with cirrhosis.

Answer 26

The American Association for the Study of Liver Diseases provides practice guidance on addressing malnutrition, frailty, and sarcopenia in cirrhosis patients, emphasizing the importance of nutritional support, physical activity, and early intervention to improve outcomes.

Question 27

Define the concept of sarcopenia in cirrhosis and discuss its implications and potential therapeutic interventions.

Answer 27

Sarcopenia in cirrhosis refers to muscle loss and weakness, which can lead to poor outcomes. Therapeutic interventions may include exercise, nutritional support, and addressing underlying causes to improve muscle mass and function.

Question 28

What are the key considerations for managing ascites in cirrhosis according to Wong F (2012)?

Answer 28

Wong F highlights the importance of sodium restriction, diuretic therapy, paracentesis, and potential use of albumin infusion in managing ascites in cirrhosis patients.

Question 29

Describe the impact of late evening meals on nitrogen balance in patients with cirrhosis of the liver according to Swart GR et al (1989).

Answer 29

Swart GR’s study suggests that a late evening meal can improve nitrogen balance in cirrhosis patients, potentially aiding in better nutritional status and overall health.

Question 30

How does malnutrition affect end-stage liver disease patients, and what are the recommendations for nutrition support according to Tsiaousi E.T et al (2008)?

Answer 30

Malnutrition in end-stage liver disease can worsen outcomes. Tsiaousi E.T et al recommend individualized nutrition support, including adequate protein intake, vitamin supplementation, and monitoring to address malnutrition in these patients.

Question 31

Summarise the guidance in Lai et al (2021)

Answer 31

The key findings include the association of frailty and sarcopenia with poor outcomes in patients with cirrhosis, the role of systemic inflammation, endocrine factors, and metabolic dysregulation in the development of frailty and sarcopenia, and the importance of physical activity in preventing or reversing frailty and sarcopenia. Core findings outline the process of how liver patients become sarcopenic

Question 32

What are the ESPEN (2020) guidelines for managing sarcopenia in liver disease? (4)

Answer 32

• Sarcopenia is a strong predictor of mortality and morbidity
• Sarcopenic cirrhotic patients, including those with sarcopenic obesity, may need a higher protein intake (1.2-1.5 g/kg/day) in conjunction with exercise to accomplish muscle replenishment (Grade B)
• ONS shall be used as first-line therapy when feeding goals cannot be attained by oral nutrition alone (grade GPP - lowest score)
• PN should be used if oral intake/EN not adequate, especially in cases of hepatic encephalopathy (grade B)

Question 33

Summarise the paper by (Guo et al., 2018) (4 points)

Answer 33

• systematic review and MA using 14 papers
• The meta-analysis showed that late evening snack (LES) therapy significantly improved markers of malnutrition in cirrhotic patients. Specifically:
• serum albumin and liver prealbumin (indicator of liver reserve ability) both increased

The paper states that protein-energy malnutrition is a common characteristic in cirrhotic patients. The improvements seen in albumin, prealbumin, and cholinesterase suggest LES can help correct this malnutrition state.

The meta-analysis also found that LES improved carbohydrate oxidation and reduced fat oxidation, indicating it can help correct the abnormal fuel metabolism seen in cirrhosis.

Question 34

Summarise the Yamanaka-Okumura et al., 2006 paper

Answer 34

RCT included 21 cirrhotic patients and 26 controls to study the metabolic effect of consumption of an evening rice ball.

Results from the study found that:

Frequency of meals, rather than overall energy intake, was associated with improved fuel metabolism in cirrhosis.

However, the study excluded alcohol related cirrhosis and all of the 47 participants were male, minimising its generalisability to the wider cirrhotic population, especially since there are known variations in the preferential metabolism of substrates between the sexes (women = depletion of adipose; Men depletion of skeletal muscle).

Question 35

Summarise the Tsien et al., 2012 paper

Answer 35

Systematic review

showed having an evening snack improved nitrogen balance, irrespective of the type of snack (included 31-100g CHO and ranged from ONS to jam on toast) - important for adherence to this dietary advice as it increases freedom of choice and reduces taste fatigue.

Based on this, it is recommended to have 4-7 small meals and a 50g CHO late evening snack, by ESPEN 2006, Grade B.

Question 36

Outline the liver’s role in carbohydrate metabolism (2)

Answer 36

• regulates blood glucose levels through glycogenesis (storing glucose as glycogen) and glycogenolysis (converting glycogen back to glucose)
• involved in gluconeogenesis, creating glucose from non-carbohydrate sources, especially during fasting or intense exercise where it maintains serum glucose concentration of 4-6mmol/L.

Question 37

Outline the livers role in protein metabolism (2)

Answer 37

o Synthesises various proteins, including enzymes, hormones, and plasma proteins.
o It plays a role in deaminating amino acids for gluconeogenesis or storage as fat, converting ammonia produced in this process into urea, which is then excreted by the kidneys.

Question 38

Outline the liver’s role in fat metabolism (2)

Answer 38

o Controls lipogenesis and B oxidation when glycogen stores are depleted.
o Essential in the emulsification process required to digest dietary fat and to absorb fat soluble vitamins (ADEK).

Question 39

Outline the liver’s role in storage of vitamins and minerals (2)

Answer 39

o Stores fat-soluble vitamins (A, K) and water-soluble vitamins (B2, 3, 6, 12 and folate), releasing them as needed.
o It also stores minerals like iron and copper, crucial for various bodily functions.

Question 40

What is the liver’s role in immune function?

Answer 40

o It synthesises acute-phase proteins which increase in response to inflammation, playing a part in the immune response.

Question 41

What are the three heamotological functions of the liver? (3)

Answer 41

o The liver is vital in synthesising clotting factors, crucial for blood coagulation.
o It produces albumin, essential for maintaining plasma colloid osmotic pressure and transporting various substances in the blood.
o The liver also plays a role in the breakdown and recycling of red blood cells to form bilirubin, using a type of macrophage called kupffer cells.

Question 42

What are the detoxification functions of the liver? (2)

Answer 42

o Filters and detoxifies substances from the blood, including metabolic by-products, drugs, alcohol, and environmental toxins.
o This is achieved through enzymatic processes in two phases: Phase I (modification) and Phase II (conjugation), transforming these substances into water-soluble forms for excretion.