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Nutrition Management

of Liver Cirrhosis
CARLY SPIRITO
Objectives
1.Provide an overview of liver cirrhosis

2. Introduce DS and provide background of medical history

3. Explain nutrition diagnosis and intervention of liver cirrhosis

4. Explore proposed outcomes and ways to monitor progress of interventions

5. Discuss how to practically use information as clinical RDs


Liver Cirrhosis: Background
o Prolonged inflammation and damage to
the liver causes scarring (known as
fibrosis)
o When scar tissue forms, it cannot function
as healthy tissue and blocks flow of blood
o Cirrhosis: When scar tissue begins to
replace healthy tissue and damage
becomes irreversible

Risk factors:
o Chronic viral infections (Hepatitis B and C)
o Fatty liver associated with obesity and
diabetes
o Alcohol abuse
Liver Cirrhosis: Symptoms
oFluid retention, swelling in the ankles, legs, abdomen
oAscites
oLoss of appetite
oDecrease in energy, fatigue
oWeight loss or sudden weight gain
oYellowing of the skin or whites of the eyes (jaundice)
oConfusion, disorientation, mood changes
oTaste changes
Nutrition Risk Factors
oInadequate dietary intake – ascites and associated discomfort,
impaired gastric and gut motility, deficiency of certain minerals may
impact taste, low sodium diet impacts palatability, fasting for clinical
investigation, irregular and poor eating habits
oMalabsorption – deficiency of vitamins/minerals and decreased fat
absorption d/t bile salt deficiency or exocrine pancreatic insufficiency
oMetabolic Disturbances – hypermetabolic state results in depleted
hepatic glycogen stores. Cirrhosis can result in an accelerated rate of
starvation.
How can we help?
oEnergy Intake: BEE + 20%, adjustments made for hypermetabolism or
desired weight loss
oProtein Intake: 1.2 -1.5 gm/kg protein or 2.0-2.5 g/kg IBW (obese)
o Avoid restricting protein with HE as it can increase protein catabolism

oMust consider the potential consequences on intake with prescribing a


low-sodium diet
oMVI may be recommended to replenish any suspected deficiencies
o Zinc and Vitamin A may improve dysgeusia

oEncourage 4-6 smaller meals throughout the day


oA high-carbohydrate, high-protein bedtime snack recommended to
improve total body protein
Introduction to DS
o64, Caucasian Male oFormer smoker - 2001
oInitial weight -128.5 kg oFamily History:
o Brain cancer – sister
oHeight - 182.88 cm
o Heart attack – Mother, father
oBMI = 40.5 (class III obesity)
oActive Problem: Anasarca, thrombocytopenia,
Previous Weight- 3 Months ago: 117.9 kg coagulopathy, localized swelling, AKI, ascites,
abdominal distention, altered mental status, C.
Percent Weight Change – 14.9 % Gain Diff, end stage liver disease, liver cirrhosis, acute
Previous Weight – 6 months ago: 120.8 kg hepatic encephalopathy, HCV
Percent Weight Change – 12.1% Gain
Patient History/Order of Events
o9/16/19: Pt. previously admitted for acute hepatic encephalopathy and recently had cardiac
stent placed by IU Hospital in anticipation for liver transplant
o9/23/19: Presented to the ER with worsening abdominal distention with SOB and in need of a
paracentesis. Struggling with anasarca as he cannot be on diuretics d/t declining kidney function
and no access to paracentesis locally
oHistory of decompensated liver disease due to Hepatitis C. Pt. reports he is a non-responder as
he has been on multiple medications with no clearance in viral load
oPt. reports he has been on the transplant list for 1 month, received cardiac stents 3 weeks ago
and must be 12 weeks post-op for transplant
oPreviously diagnosed with Clostridium Difficile during last admission and has been on
Vancomycin since.
Anthropometric Data
9/24/19 9/26/19 9/28/19

Current Weight in Kgs: 135.5 kg Current Weight in Kgs: 137.4 kg Current Weight in Kgs: 134.1 kg
Standard Body Weight/Dry Standard Body Weight/Dry Standard Body Weight/Dry
Weight: 128.5 kg Weight: 128.5 kg Weight: 128.5 kg
Weight Comments: ascites, +3 Weight Comments: pt. up 1.7 kg Weight Comments: pt. down 3.3
pitting edema since last visit r/t continued kg since last visit r/t hemodialysis,
ascites and edema ascites continues
Height: 182.88 cm
Height: 182.88 cm Height: 182.88 cm
Body Mass Index: 40.5 (Class III
Obesity) Body Mass Index: 41.1 (Class III Body Mass Index: 40.1 (Class III
Obesity) Obesity)
Pertinent Labs
9/24/19 9/26/19 9/28/19
Hgb: 9.7 gm/dl (13.6-17.0)
Hct: 27.9% (40.0-54.0) WBC: 3.7 K/mm3 (3.9-10.5) Hgb: 7.6 gm/dl (13.6-17.0)
BUN: 26 mg/dL (9-20) Hgb: 8.9 gm/dl (13.6-17.0) Hct: 21.3% (40.0-54)
GFR: 44 (>60) Hct: 25.3% (40.0-54) BUN: 30 mg/dL (9-20)
Creatinine: 1.60 mg/dL (0.66-1.25) Sodium: 136 mmol/L (137-145) Creatinine: 1.70 mg/dL (0.66-1.25)
Bilirubin: 10.3mg/dL (0.3-1.2) BUN: 29 mg/dL (9-20) AST: 76 U/L (17-59)
AST: 131 U/L (17-59) Creatinine: 1.60 mg/dL (0.66-1.25) Albumin: 3.1 g/dL (3.5-5.0)
ALT: 51 U/L (<50)
Alkaline Phos: 137 U/L (38-126)
Pertinent Medications
Medication Nutrition Side Effects/Contraindications
Lasix ↑K, ↑Mg, ↓cal, ↓Na, may be recommended
Hydrocodone Anorexia, delays digestion
Dilaudid Anorexia, ↓wt., ↑ thirst, dehydration
Lactulose High fiber w/ 1500-2000mL fluid/day to prevent
constipation, ↑ absorption of Ca & Mg
Protonix May ↓ absorption of Fe & vitamin B12
Spironolactone Avoid excessive K intake, K supp., salt substitutes
Inadequate oral intake related to acute on chronic illness, as evidenced
by recorded daily intake meeting <75% energy and <50% protein needs
according to minimum recommendations.

Inadequate protein intake related to increased nutrient needs d/t to


liver cirrhosis, as evidenced by recorded average 3-day intake meeting
<50% protein needs according to minimum recommendations.
(updated)

Inadequate protein intake related to increased nutrient needs d/t liver


cirrhosis, as evidenced by recorded average 5-day intake meeting <50%
protein needs according to minimum recommendations. (updated)

NUTRITION DIAGNOSIS AND PES STATEMENT


Interventions (Initial)
oInitial assessment 9/24/19: Trigger for poor po intake >5 days.
oThe pt’s calculated energy needs were ~2000 calories/day, using 25 kcal/kg/day x IBW. Calculated protein
needs were 156-195gm/day using factors of 2.0-2.5g/kg x IBW.
oPt. intake at initial assessment meeting ~61% energy and ~29% protein needs, ordered Ensure High Protein
to be sent once daily.
oGI consult report on 9/24/19 shows the plan is to proceed with a 2 gm sodium, high-protein diet.
oLarge volume paracentesis attempted on 9/25/19, however only 500 cc fluid was removed.
oFollow-up 9/26/19: Pt. reported swelling was causing him abdominal pain, bloating, and gas. Encouraged
pt. to try and eat smaller meals/snacks throughout the day. Discussed purpose of a low-sodium diet to
prevent fluid retention and explained menu options. Pt. reported he loved the Chocolate Ensure HP.
oAverage 2-day intake meeting ~75% energy and ~44% protein needs. Ordered Chocolate Ensure High
Protein to be sent BID.
Interventions (After Transfer to ICU)
oAttempts were made to diurese pt. with Lasix and albumin IV. Sandostatin was also started by
nephrology. This regimen had little effect on swelling and the pt. developed severe abdominal
cramping, it was then discontinued.
oDialysis catheter placed on 9/27/19. Pt. underwent one round of ultrafiltration and 3L of extra fluid
were removed.
oFollow-up 9/28/19: Pt. continues drinking Ensure HP 2x/day. Discussed increased protein needs in
relation to HD treatment. Offered sending pt. an evening snack of 1/2 a turkey sandwich, which he
declined. Discussed further options for snacks/supplementation but pt. was unwilling to try anything
else at this time.
oAverage 4-day intake meeting ~80% energy and ~44% protein needs. FNS made aware to send 1.5
servings protein with each meal.
oDue to the pt’s declining clinical status he was transferred to IU on 9/28/19, where his hepatology
team agreed to proceed with care.
Proposed Outcomes to Monitor and
Evaluate
Nutrition Biochemical
Food & Beverage
Focused Physical Data/Medical
Intake
Assessment Tests/Procedures

Medical Food
GI symptoms
Supplement Weight Changes
improvement
Intake

Energy Needs Protein Needs Food & Nutrition


Met Met Knowledge/Skill
Questions?
References
Academy of Nutrition and Dietetics. (n.d.). Cirrhosis: Disease Process. In Nutrition Care Manual.
Retrieved October 4, 2019, from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=18609&lv3=26
8348&ncm_toc_id=268348&ncm_heading=Nutrition%20Care
Academy of Nutrition and Dietetics. (n.d.). Gastrointestinal disease: Cirrhosis. In Nutrition Care
Manual. Retrieved October 4, 2019, from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=18609&ncm_to
c_id=18609&ncm_heading=Nutrition%20Care
Academy of Nutrition and Dietetics. (n.d.). Cirrhosis: Nutrition Intervention. In Nutrition Care Manual.
Retrieved October 4, 2019, from
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=18609&lv3=26
8359&ncm_toc_id=268359&ncm_heading=Nutrition%20Care
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Cleveland Clinic. (2019, January). Cirrhosis of the liver. Retrieved from
https://my.clevelandclinic.org/health/diseases/15572-cirrhosis-of-the-liver
References
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