MNT for Liver Disease Part 2 Flashcards
_____ _____ is a syndrome characterized by impaired mentation, neuromuscular disturbances, and altered consciousness
Hepatic encephalopathy
The pathogenesis of hepatic encephalopathy is unknown, but two theories include…
-Elevated ammonia levels
-Increased aromatic amino acids (AAA) and decreased branched-chain amino acids (BCAA)
Symptoms of stage I of hepatic encephalopathy:
-Mild confusion
-Irritability
-Decreased attention
Symptoms of stage II of hepatic encephalopathy:
-Lethargy
-Disorientation
-Inappropriate behavior
-Drowsiness
-Asterixis (uncontrolled flapping of hands)
Symptoms of stage III of hepatic encephalopathy:
-Somnolent but arousable
-Confused
-Incomprehensible speech
Symptoms of stage IV of hepatic encephalopathy:
Coma
Precipitating causes of hepatic encephalopathy:
-GI bleeding (source of ammonia)
-Uremia
-Constipation (more time for bacteria to produce ammonia)
-Muscle catabolism (ammonia)
-Fluid and electrolyte abnormalities
-Infection
-Sedatives
-Portacaval shunts
-Excessive dietary protein (rare)
What two drugs can be used to treat hepatic encephalopathy?
-Lactulose
-Rifaximin
Lactulose is an ____ ____ that removed excess ammonia
Osmotic diuretic
What are food medications with Lactulose?
-Diarrhea
-Flatulence
-N/V
Rifaximin decreases colonic ____ production
Ammonia
Are there any food-drug interactions with Rifaximin?
No
With hepatic encephalopathy, a ____ restriction is no longer recommended
Protein
A low-protein diet increases catabolism of ___ ___ ___, which worsens hepatic encephalopathy
Lean body mass
Protein recommendation for someone with hepatic encephalopathy:
1.0-1.5 g/kg
For patients with hepatic encephalopathy requiring tube feeding, use a formula with appropriate ____ content
Protein
MNT for chronic hepatic encephalopathy includes…
-High fiber
-High dairy (casein is lower in AAA and higher in BCAA)
-Vegetarian diet can be used since vegetable protein is high in BCAA
_____ Syndrome is acute kidney failure in the absence of prior kidney disease due to decreased renal blood flow
Hepatorenal
Those with hepatorenal syndrome may require _____
Dialysis
MNT for hepatorenal syndrome:
-Possible restriction of fluid, Na, K+, and phosphorus (depending on treatment modality)
In end-stage liver disease, someone would have increased levels of ____, ____, and ____ due to the catabolic state
Glucagon, epinephrine, and cortisol
Someone with end-stage liver disease would have decreased synthesis of…
-Serum albumin
-Transport proteins
-Clotting factors
Someone with end-stage liver disease would have increased ____ levels
Ammonia
Early in end-stage liver disease, someone might experience ____ due to peripheral insulin resistance and decreased glucose uptake
Hyperglycemia
Late in end-stage liver disease, someone might experience fasting hypoglycemia due to…
-Loss of hepatic glycogen stores
-Decreased gluconeogenesis
Someone with end-stage liver disease has increased _____, leading to a depletion of fat reserved
Lipolysis
Fat malabsorption with end-stage liver disease may occur due to…
-Decreased production of bile
-Blocked bile ducts (cholestatic liver disease)
Someone with end-stage liver disease may have decreased ____, ____, ____, and ____ of micronutrients (also altered metabolism of micronutrients)
Intake, absorption, transport, and storage
Malnutrition is present in ____-___% of patients with cirrhosis
50-90
Malnutrition is more common in those with ____ liver disease
Alcoholic
____ is a defining feature of malnutrition in decompensated end-stage liver disease
Sarcopenia
Malnutrition is associated with…
-Compromised immune and respiratory function
-Delayed wound healing
-Longer hospital stays
-Increased risk for mortality
What are factors that lead to malnutrition in someone with end-stage liver disease?
-Inadequate oral intake
-Disturbances in macronutrient metabolism, leading to catabolism
-Decreased capacity of the liver to store nutrients
-Malabsorption of fat
What factors lead to inadequate intake in someone with end-stage liver disease?
-Anorexia
-N/V
-Dysgeusia
-Early satiety
-Restrictive diets
-Alcohol abuse
-Financial issues
-Food-medications interactions
What leads to malabsorption of fat?
-Decreased transport of bile via bile ducts
-Decreased bile acid production by the liver
What traditional assessment parameters are affected by liver disease?
-Weight, BMI, and %wt change are affected by fluid status
-Decreased synthesis of transport proteins (e.g., albumin, prealbumin)
-Hyperammonemia and hepatorenal syndrome affect validity of nitrogen balance studies
What should we ask in the diet history portion of the nutrition assessment for someone with end-stage liver disease?
-Appetite
-Weight change
-Taste changes
-Persistent GI problems
-Assessment of dietary intake
-Previous diet
-Supplement use
What should be looked in the NFPE for someone with end-stage liver disease?
-Muscle wasting
-Fat stores
-Ascites or edema
-Micronutrient deficiencies
In the nutrition assessment, we should also evaluate the current diagnosis, along with ____ and ____
Complications and PMHx
What lab assessments are included in the Liver Function Tests?
-Albumin
-NH3 (Ammonia)
-Total bilirubin (indirect/unconjugated and direct/conjugated)
-Prothrombin time
-Alanine aminotransferase
-Aspartate aminotransferase
-Alkaline phosphatase
-Gamma-glutamyl transpeptidase
All nutrition calculations for someone with end-stage liver disease should be based on ___ weight
Dry
What are some options to use if dry weight is unavailable?
-Use IBW
-Adjust body weight based on the amount of ascites and peripheral edema
If someone has mild ascites and dry weight is unknown, subtract ____% from body weight
5
If someone has moderate ascites and dry weight is unknown, subtract ____% from body weight
10
If someone has severe ascites and dry weight is unknown, subtract ____% from body weight
15
We can subtract an additional ___% from body weight if pedal edema is present
5
To calculate energy requirements for someone with end-stage liver disease, use ___ ____ if possible
Indirect calorimetry
Calories requirements for those with end-stage liver disease:
25-35 kcal/kg
Malnourished patients may need up to ____ kcal/kg to promote anabolism
40
Protein recommendations for someone with end-stage liver disease:
1.2-1.5 g/kg
For someone with end-stage liver disease, we should monitor for _____, and they may need insulin and a consistent carbohydrate diet
Hyperglycemia
Someone with end-stage liver disease may experience ____ hypoglycemia
Fasting
MNT for someone who is experiencing hyperglycemia or fasting hypoglycemia:
-Small, frequent meals and an evening snack
-Avoid alcohol
For someone with end-stage liver disease, ___% of their total kcal should come from fat
30
However, if someone is having steatorrhea, they should be on a ___ gram low-fat diet
40
If someone has hypervolemia and severe hyponatremia (serum Na <125 mEq/L), a fluid restriction of ___-___ L/d may be indicated
1-1.5
How should we monitor fluid intake?
-Input/output records
-Weight
-Serum sodium
If someone has ascites or edema, they should have a ____ gram sodium restriction
2
We should also monitor ____ due to diuretics and paracentesis
Electrolytes
For those with end-stage liver disease, we should provide a ____
Multivitamin
Many end-stage liver disease patients should be given fat-soluble vitamin supplements, and if someone has malabsorption, they should be given in ___-____ form
Water-soluble
> 90% of patients with advanced liver disease are deficient in Vitamin ___
D
If someone has alcoholic liver disease, they should receive ___-___ mg of Thiamin and ____ mg of folic acid daily
50-100; 1
Many people with end-stage liver disease are deficient in vitamin ___
K
We should also provide the ____ of minerals, except in specific conditions
DRI
Someone with cholestatic liver disease should not receive ____ and ____ supplementation
Copper and manganese
Someone with hemochromatosis should not receive any ____ supplementation
Iron
Someone with Wilson’s Disease should not receive ____ supplementation
Copper
If someone is having GI bleeding, they may need increased _____ supplementation
Iron
If someone has alcoholism, they may require increased ____ and ____ supplementation
Zinc and Magnesium
If someone is on a Diuretic, they may need increased ____, ____, ____ and ____
K+, zinc, magnesium, and calcium
If someone is having Steatorrhea, they may need increased ____, ____, and ____
Calcium, Magnesium, and Zinc
General recommendations for someone with end-stage liver disease:
-Small, frequent meals with a bedtime snack
-Avoid skipping meals
-Nutrient-dense snacks
-Poor appetite: nutrition supplements
Someone with end-stage liver disease may require enteral nutrition due to…
-Poor intake
-Malnutrition
-Altered mental status
-Intubation
Someone with end-stage liver disease on enteral nutrition should get a high ___ formula
Protein
A small-bore ____ tube is appropriate for someone with non-bleeding esophageal varices
Nasogastric/nasoenteric
A ____ placement is not recommended for those with ascites or gastric varices
PEG
Parenteral nutrition would be indicated for someone with…
-Non-functioning GIT
Parenteral nutrition can lead to…
-Hepatic steatosis
-Cholestasis
-Possible cirrhosis
For someone on parenteral nutrition, we should avoid _____ of carbohydrates, lipids, or total kcal
Overfeeding
For someone on parenteral nutrition, a lipid emulsion should not provide more than ____ g/kg/d
1
A ____ ____ solution of parenteral nutrition should be given to someone with end-stage liver disease
Mixed substrate
____ administration of parenteral nutrition is recommended for those with parenteral nutrition
Continuous
For patients with cholestatic liver disease, reduce ____ and ____ provided
Copper and Manganese
____ ____ is the leakage of chyle into the peritoneal cavity due to obstruction or leak from abdominal lymphatics
Chylous ascites
Possible etiologies of chylous ascites:
-Malignant obstruction
-Abdominal surgery: AAA repair, Liver transplant
-Congenital defects of the lymphatics
Chyle is made up of…
-White blood cells
-Chylomicrons
-Fat-soluble vitamins
-Protein
-Fluid
-Electrolytes
Consequences of chylous ascites:
-Pain
-Anorexia
-Hypoalbuminemia
-Decreased electrolyte levels
-Fat-soluble vitamin depletion
-Essential fatty acid deficiency
Medical management of chylous ascites includes…
-Conservative management (drainage, reducing chyle flow)
-Surgical repair
The goal for MNT for chylous ascites is to reduce long-chain triglyceride (LCT) intake to less than ____ g/day while still providing adequate nutrition
10
Options for diet for someone with chylous ascites:
-Very low-fat oral diet with MCT supplementation
-NPO with TF using a very low-fat elemental formula
-NPO with TPN
Someone with chylous ascites should receive a high _____ diet
Protein
