jagomart
digital resources
picture1_Nutrition In Surgical Patients Pdf 137911 | Nutritionreviews66 0047


 145x       Filetype PDF       File size 0.14 MB       Source: boris.unibe.ch


File: Nutrition In Surgical Patients Pdf 137911 | Nutritionreviews66 0047
nutrition in clinical care roleofnutritioninlivertransplantation for end stage chronic liver disease felix stickel daniel inderbitzin and daniel candinas patients with end stage liver disease often reveal signicant protein energy malnutrition ...

icon picture PDF Filetype PDF | Posted on 06 Jan 2023 | 2 years ago
Partial capture of text on file.
                Nutrition in Clinical Care
                Roleofnutritioninlivertransplantation for end-stage chronic
                liver disease
                Felix Stickel, Daniel Inderbitzin, and Daniel Candinas
                                  Patients with end-stage liver disease often reveal significant protein-energy
                                  malnutrition, which may deteriorate after listing for transplantation. Since
                                  malnutrition affects post-transplant survival, precise assessment must be an
                                  integral part of pre- and post-surgical management.Whilethereiswideagreement
                                  that aggressive treatment of nutritional deficiencies is required, strong scientific
                                  evidence supporting nutritional therapy is sparse. In practice, oral nutritional
                                  supplementsarepreferredoverparenteralnutrition,butenteraltubefeedingmaybe
                                  necessarytomaintainadequatecalorieintake.Proteinrestrictionshouldbeavoided
                                  and administration of branched-chain amino acids may help yield a sufficient
                                  protein supply. Specific problems such as micronutrient deficiency, fluid balance,
                                  cholestasis, encephalopathy, and comorbid conditions need attention in order to
                                  optimize patient outcome.
                                  ©2008International Life Sciences Institute
                                     INTRODUCTION                               its failure to accurately predict survival in approximately
                                                                                15–20%ofpotentialtransplantrecipientsrelatestothefact
                Orthotopic liver transplantation (OLT) has greatly              that malnutrition does not influence MELD figures.
                improved the prognosis of patients with chronic liver                Nocontroversycurrentlyexistsregardingtheimpor-
                failure, and clinical features of declining liver function      tance of nutritional status as an important predictor of
                largelynormalizefollowingsuccessfulorganreplacement.            post-transplant outcome and the benefits of its therapeu-
                Amongthemostprevalentcomplicationsofchronicliver                tic improvement, although evidence from randomized
                failure is a marked impairment of the nutritional status        clinical trials is limited. The present review aims to sum-
                due to both primary and secondary malnutrition. The             marizethecurrentevidenceonnutritionalaspectsinliver
     | downloaded: 5.1.2023degree of malnutrition has been a parameter of the oldtransplantation both in the pre- and post-transplant
                version of the Child-Pugh index; however, the lack of           setting in order to highlight the importance of sufficient
                universally applicable diagnostic tools to precisely diag-      nutritional support as a valuable intervention to improve
                nosemalnutritioninclinicalpracticehasleftthediagnosis           patients overall prognosis and quality of life.
                based on clinical signs of encephalopathy and ascites as
                well as the laboratory parameters serum bilirubin, serum
                                                           1
                albumin, and prothrombin time (index). Interestingly,             PREVALENCEANDSIGNIFICANCEOFMALNUTRITION
                the model for end-stage liver disease (MELD), initially                       INEND-STAGELIVERDISEASE
                developedforpredictionofsurvivalofpatientswithcom-
                plications of portal hypertension scheduled for a trans-        With the exception of patients with fulminant hepatic
                jugular intrahepatic portosystemic shunt, is now widely         failure, most candidates for OLT present with significant
                usedfororganallocationinlivertransplantprogrammes,              malnutrition, and nutritional deficiencies usually evolve
                                                                2
                butit does not consider nutritional status at all. Possibly,    prior to clinical signs of hepatic insufficiency. Protein
                Affiliations: F Stickel is with the Institute of Clinical Pharmacology, Inselspital, University of Berne, Berne, Switzerland. D Inderbitzin and
                DCandinasarewiththeDepartmentofVisceralandTransplant Surgery, Inselspital, University of Berne, Berne, Switzerland.
    https://doi.org/10.7892/boris.28346Correspondence: F Stickel, Institute of Clinical Pharmacology, University of Berne, Murtenstrasse 35, 3010 Berne, Switzerland. E-mail:
                felix.stickel@ikp.unibe.ch, Phone: +41-31-632 8715, Fax: +41-31-632 4997
                Keywords:branched-chainaminoacids,livertransplantation,nutritionaltherapy, protein malnutrition
    source:     doi:10.1111/j.1753-4887.2007.00005.x
                Nutrition Reviews® Vol. 66(1):47–54                                                                                   47
               energy malnutrition (PEM), in particular, is frequently             drates, lipids, proteins, vitamins, and trace minerals; it is
               encountered in patients with cirrhosis of nearly every              also an importantpartof theimmunesystem.Literallyall
                        3                                                          functionalpropertiesof theliverareprofoundlyimpaired
               etiology. Even in stable cirrhotic patients, who are com-
               monly referred to as having Child A cirrhosis, protein              in end-stage liver disease (ESLD). Malnutrition in
                                                                           4       patients with ESLD has numerous causes,some of which
               depletion is prevalent in approximately 20% of patients.
               This figure rises sharply as liver insufficiency progresses,           relate to the underlying etiology of liver damage while
               and a majority of patients with Child C cirrhosis have              others are universal features of declining liver function
                                                    5–8
               significant nutritional deficiencies.     PEMclinically pre-          irrespective of the type of liver disease.Both primary and
               sents with weakness,muscle wasting,weight loss,nausea,              secondary factors contribute to poor nutritional status
               and anorexia; its prevalence is similar in advanced alco-           and must be accounted for in the management of these
                                                                       7,9
               holic liver disease and other causes of liver cirrhosis.   In       patients. The most relevant causes of malnutrition in
               alcoholic cirrhosis, PEM is closely associated with com-            patients with ESLD are as follows: 1) Dietary insuffi-
               plications of cirrhosis including infections, encephalopa-          ciency:a)anorexia,nausea,vomiting;b)earlysatiety,taste
                                                                         10,11     abnormalities, poor palatability of diets (protein and salt
               thy, development of ascites, and variceal bleeding,
               as well as with reduced patient and graft survival after            restriction);c) reflux disease (ascites,abnormalgutmotil-
               OLT.12,13                                                           ity): 2) Malabsorbtion: a) pancreatic insufficiency; b)
                    Patients with end-stage liver disease are often defi-           cholestasis (fat soluble vitamins); c) drug-related diar-
                                                                           14      rhoea(lactulose,antibiotics,diuretics,cholestyramine):3)
               cient in various vitamins and other micronutrients.
               Cirrhotic alcoholics are especially susceptible to severe           Metabolicdisturbances:a)hypermetabolismduringcom-
               vitamin depletion, particularly that of folate and                  plications (infections, haemorrhage, ascitic decompensa-
               pyridoxal-5′-phosphate,the biologically active coenzyme             tion);b)proteincatabolism(inflammation,impairedliver
                                                                           15      synthesis); c) impairment of glucose homeostasis due to
               of vitaminB6,withbothoccurringinupto70%ofcases.
               Thiamine levels are also frequently decreased in patients           hepatic insulin resistance (altered gluconeogenesis, low
               with alcoholic and hepatitis C-related cirrhosis, which             glycogen stores, impaired glycogenolysis); d) increased
               may elicit the Wernicke-Korsakoff syndrome and Beri-                 lipolysis, enhanced lipid oxidation; e) proinflammatory
                                       16
               Beri cardiomyopathy.       A typical feature of early and           cytokines (TNFa, interleukins, leptin): 4) Iatrogenic: a)
               advanced alcoholic liver disease is an increasingly severe          investigativeprocedure-relatedfastingperiods;b)protein
               reduction of hepatic vitamin A stores, which sometimes              restriction during periods of encephalopathy; c) large
               leads to infertility and night blindness.17 In vitamin              volume paracentesis.
               A-deficient cirrhotics, its supplementation, even at rela-               Notably, the majority of patients with ESLD have
               tively moderate doses, may further aggravate liver injury           no increased resting energy expenditure (REE).A recent
               since high-dose vitamin A preparations may be hepato-               study found a normal energy balance in clinically
               toxic due to polar retinoid metabolites that cause hepato-          stable cirrhotic patients with malnutrition as assessed
                                                                   18,19                               25
               cellular apoptosis and may promote fibrogenesis.         Zinc        by anthropometry.      Seventy-four consecutive cirrhotic
               deficiency is common in patients with decompensated                  patients and nine healthy controls were investigated
               cirrhosis and likely relates to decreased absorption and a          using indirect calorimetry adjusted according to the
               diuretics-induced increase in its urinary excretion.Clini-          patients physical activity. Thirty-two patients in the cir-
               cally, zinc deficiency presents with alterations of smell            rhoticgroupwereclassifiedasseverelymalnourished,but
               and taste, protein metabolism, and encephalopathy.                  basal energy expenditure (BEE) was similar in all three
               Regarding the latter, one study showed that zinc supple-            groups; the non-protein respiratory quotient was lower
               mentationresulted in lower ammonia levels following an              in cirrhotics notwithstanding their nutritional status.
               alanine challenge, and improvements of psychometric                 In addition, no difference in the estimated daily energy
                                                             20 but another
               tests, liver function, and Child-Pugh score,                        expenditure and energy intake was observed among
                                                        21
               study did not replicate these findings.                              groups.
                    Reduced nutritional status has been identified as                   Amajorreasonforprimarymalnutrition in patients
               an independent predictor of poor prognosis in patients              priortotransplantationisreducedfoodconsumptiondue
                                    22,23                                                       26
               with liver cirrhosis      and an indicator of unfavorable           to anorexia.   Low calorie intake may also be traced to
                                                     24
               outcome after liver transplantation.                                several other reasons including unpalatable diet compo-
                                                                                                                                23
                                                                                   sition due to salt and protein restriction,    early satiety
                                                                                                                                 27
                             CAUSESOFMALNUTRITIONIN                                because of ascites and portal gastropathy,      and loss of
                               END-STAGELIVERDISEASE                               appetite due to upregulated mediators of inflammation
                                                                                   and mediators of appetite such as tumor necrosis factor-
               The liver is the largest metabolic organ of the human               alpha and leptin.28,29 In addition, in up to 45% of cirrhot-
               body and plays a prime role in the turnover of carbohy-             ics coexistinginfectionwithHelicobacterpylorimaycause
               48                                                                                                 Nutrition Reviews® Vol. 66(1):47–54
                                                                                   30                        values for triceps skin fold thickness and MAMC as
                     dyspepsia and a decreased desire for food.                       Significant
                     malnutrition may be the result of maldigestion related to                               simple bedside tests for nutritional assessment are given
                     pancreatic or biliary abnormalities such as exocrine pan-                               in Table 1.BMI in particular has been criticized for yield-
                     creatic insufficiency or primary biliary liver disorders,                                 ing falsely high values,but correction by subtracting esti-
                     while malabsorbtion can result from applied medications                                 matedamountsof ascites and other fluid collections may
                                                                                         31                                                                                       8
                     such as lactulose or antibiotics causing diarrhea.                                      compensate for this disadvantage to some extent.
                            Impaired glucose tolerance due to insulin resistance                                   Biochemical markers of malnutrition include serum
                     and established diabetes has an important impact on                                     albumin concentration and measurements of 24-hour
                     nutritional status in many cirrhotic patients. Due to                                   creatinine excretion related to a reference population.
                     impaired glyconeogenesis,the cirrhotic liver fails to store                             While the former obviously varies significantly due to
                     sufficient amounts of glycogen; this results in glyconeo-                                 hepatic function,the latter has been suggested as an indi-
                     genesis from protein catabolism and lipid oxidation.32                                  rect measure of body muscle mass, as 1 g of excreted
                     Therefore, periods of fasting should be avoided in cir-                                 creatinine equals 18.5 kg of muscle mass.37 A more
                     rhotic patients, and frequent meals should be imple-                                    sophisticated, but less widely available, examination tool
                     mented to prevent protein catabolism. In fact, late                                     for assessing body composition is bioelectric impedance
                     evening meals and nocturnal glucose supplementation                                     analysis(BIA).BIAisapreciseandnoninvasivetechnique
                     has been shown to improve nitrogen balance in cirrhotic                                 that measures lean body mass and fat stores; however,
                                 33,34
                     patients.                                                                               it also becomes inaccurate when patients retain fluid.
                                                                                                             Another noninvasive method is dual x-ray absorptiom-
                                         NUTRITIONALASSESSMENT                                               etry(DEXA),whichprovidesexactmeasurementsoftotal
                                                                                                             bodycomposition.Again,itsaccuracydeclinesinpatients
                     For assessing nutritional status in patients with ESLD                                  with ascites and edema. These shortcomings may be
                     on the transplant waiting list no accepted diagnostic                                   bypassed with more precise approaches such as in vivo-
                     “gold standard” exists; in fact, several surrogate markers                              neutron activation analysis and isotope dilution tech-
                                                                                                                       38  but since application of these methods is
                     of an individuals nutritional status are usually necessary                             niques,
                     to obtain valid data on the severity and pattern of                                     time-consuming and costly, their use is restricted to
                     malnutrition.                                                                           research purposes.
                            Oneuseful,easily applicable,and validated approach                                     Considering these feasibility issues, the European
                     is subjective global assessment (SGA). This method inte-                                Society for Parenteral and Enteral Nutrition (ESPEN) has
                     grates a detailed medical and dietary history,body weight                               publishedupdatedguidelinesonenteralnutritioninliver
                                                                                                                                            39
                     and height, coexisting medical conditions, and physical                                 transplant candidates.             The current guidelines recom-
                     activity to rate patients either “well-nourished”,“moder-                               mend simple bedside methods such as SGA and/or
                     ately malnourished”, or “severely malnourished”. The                                    anthropometry parameters to identify patients at risk for
                     dietary history is ideally recorded by an experienced                                   poor nutritional status and BIA to quantify undernutri-
                     dietician.SGAishighlyspecific(96%)forthedetectionof                                      tion despite the limitations of all techniques in patients
                                                                                                                                                      39
                                                                                  35                         with ascitic decompensation.                According to the ESPEN
                     malnutrition in liver transplant candidates,                    butitlacks              expertpanel,othercompositenutritionscoresprovideno
                                                                                                   36
                     sensitivity in patients with severe alcoholic liver disease.                            additional prognostic information.
                            Easily applicable techniques include anthropometric
                     measurements such as body mass index (BMI), triceps
                     skin fold thickness, and mid-arm muscle circumference                                      NUTRITIONALINTERVENTION–THERAPEUTICAIMS
                     (MAMC). Unfortunately, most of the easily applicable
                     methods are confounded by significant fluid retention in                                  Patients with ESLD on the transplant waiting list
                     cirrhotics with ascites and peripheral edema. Reference                                 frequently display a gradual decline of their nutritional
                                                   Table 1 Bedside tests for simple assessment of malnutrition.
                                                   Anthropometric test                    Normal                         Moderate                   Severe
                                                   Triceps skin fold thickness
                                                       Men                                  7.5–12.5mm                     4–6mm                    <4mm
                                                       Women                                 10–16.5mm                     5–8mm                    <5mm
                                                   Mid-armmusclecircumference
                                                       Men                                23.0–25.5cm                    18–20cm                    <18cm
                                                       Women                                 21–23cm                       6–18.5cm                 <16cm
                                                                                    22
                                                   AdaptedfromSelbergetal. (Hepatology 1997;25:652–657).
                     Nutrition Reviews® Vol. 66(1):47–54                                                                                                                                 49
                      Table 2 Harris-Benedict equation.                                                       tures, calcium and vitamin D supplementation should be
                                                                                                                                                             23
                      Gender              Resting energy expenditure                                          combined with bisphosphonates.
                      Female              66.5+(9.56¥bodyweight[kilogram])+
                                             (1.85 ¥ height [centimetres]) –                                                 ROUTEOFNUTRITIONALSUPPORT
                                             4.676¥age(years)
                      Male                66.5+(13.75¥bodyweight[kilogram])+
                                             (5.0 ¥ height [centimetres]) –                                   Nutritional supplements should,ideally, be administered
                                             6.75¥age(years)                                                  enterally, either by oral supplements or,if active eating is
                                                                                                              hampered,throughagastricorjejunaltubesincepatients
                                                                                                              appear to benefit from topical nutritional factors in the
                    condition. As a result, the major goals of pre-transplant                                 gut. Another argument favoring oral nutrition is the
                    nutritional therapy are to prevent further nutrient and                                   lower rate of infections that may occur with central
                    protein depletion and to correct macro- and micronutri-                                   venous catheters.Concerns such as precipitating variceal
                    ent deficiencies. Nutritional support should include the                                   hemorrhage while inserting the feeding tube have not
                                                                                                              been confirmed in clinical trials.44 However, reports of
                    administrationof sufficientamountsof calories,proteins,                                     complications related to malpositioned feeding tubes
                    vitamins,minerals,andtraceelementswithoutexacerbat-                                       continue to surface; most are due to inadvertent disloca-
                    ing liver disease-related complications such as portosys-                                 tion in the respiratory tract causing aspiration, especially
                    temic encephalopathy, fluid retention, and electrolyte                                     when the tube is placed in the esophagus. Other
                    imbalances. Determining the extent of nutritional                                         complications observed occasionally with nasogastric/
                    supplementation requires calculation of the individuals                                  nasoduodenal tubes include epistaxis, sinusitis, tube
                    energy needs; this can be done by calculating BEE using                                   removal or retraction, tube clogging, and tube-feeding-
                    the Harris Benedict equation while considering the ideal                                  associated diarrhea.45,46 However, complications related
                    body weight rather than the patients actual weight                                       to malpositioned feeding tubes are usually preventable
                    (Table 2).As a rule of thumb, the total calories should be                                if  correct placement is safely achieved and regularly
                    aminimumof1.2timestheBEE,equalling35–40kcal/kg                                            monitored.
                    body weight daily, and 60–70% should derive from car-                                           Totalparenteralnutrition(TPN)shouldberestricted
                                     40
                    bohydrates.                                                                               to patients who are unable to eat or those for whom
                           Portosystemic encephalopathy is frequent in OLT                                    enteral feeding is contraindicated. In cases of severe gas-
                    candidates with ESLD, and many clinicians implement                                       trointestinal dysfunction, such as esophageal bleeding or
                    protein restriction to treat it. However, this should be                                  intestinal obstruction, TPN remains an option to ensure
                    avoided as a routine measure since it aggravates PEM.                                     adequate caloric intake.However,TPN is associated with
                    Instead, encephalopathy should be treated aggressively                                    higher risks of infection and electrolyte imbalance, it is
                    with standard therapy using lactulose and treatment of                                    moreexpensive,and since evidence supporting its use in
                    precipitating causes such as infections and gastrointesti-                                ESLD stems from studies focused on the treatment of
                    nal hemorrhage. Usually, standard amino acid formulas                                     severe alcoholic liver disease, it may not apply to patients
                    are well tolerated and should provide at least 1g                                                                                       9,23
                    protein/kg body weight per day, which can be increased                                    waiting for liver transplantation.
                                                                        23,40,41
                    to 1.2–2.0 g/kg daily when tolerated.                       Theusefulness
                    of branched-chain amino acids (BCAA) has not been                                                     NUTRITIONALTHERAPYBEFORELIVER
                    specifically investigated in patients with ESLD on the                                                               TRANSPLANTATION
                    transplant waiting list, but it can be assumed that the
                    supportive evidence from two recent randomized trials                                     Until now,only two prospective controlled trials investi-
                    suggesting that long-term (<12 months) nutritional                                        gated the effect of pre-transplant nutritional therapy on
                                                                                                                                                                                             47
                    supplementation with oral BCAA is beneficial in slowing                                    the outcome of patients undergoing OLT. Chin et al.
                    the progression of hepatic failure and prolonging event-                                  prospectively included 19 children with ESLD, with a
                    free survival in liver cirrhotics also applies for OLT                                    median age of 1.25 years, to compare a high-energy,
                                    42,43
                    candidates.           In practice, whole-protein formulas are                             isoenergetic and isonitrogenous BCAA-enriched semi-
                    generally recommended, and BCAA-enriched formulas                                         elemental formulation with a matched standard semi-
                    should be used in patients who develop encephalopathy                                     elemental formation. Only 12 of 19 patients completed
                    during refeeding.                                                                         the study before OLT, and only 10 of 19 completed a full
                           Osteopenia and osteoporosis is frequent in patients                                crossover study. Both regimens improved weight and
                    withESLD;therefore,calciumandvitaminDsupplemen-                                           height, whereas the BCAA formula resulted in signifi-
                    tation is recommended for all patients on the waiting list.                               cantly more pronounced improvements of total body
                    Inthosewithestablishedosteoporosisorahistoryoffrac-                                       potassium,mid-upper-armcircumference,andsubscapu-
                    50                                                                                                                                 Nutrition Reviews® Vol. 66(1):47–54
The words contained in this file might help you see if this file matches what you are looking for:

...Nutrition in clinical care roleofnutritioninlivertransplantation for end stage chronic liver disease felix stickel daniel inderbitzin and candinas patients with often reveal signicant protein energy malnutrition which may deteriorate after listing transplantation since aects post transplant survival precise assessment must be an integral part of pre surgical management whilethereiswideagreement that aggressive treatment nutritional deciencies is required strong scientic evidence supporting therapy sparse practice oral supplementsarepreferredoverparenteralnutrition butenteraltubefeedingmaybe necessarytomaintainadequatecalorieintake proteinrestrictionshouldbeavoided administration branched chain amino acids help yield a sucient supply specic problems such as micronutrient deciency uid balance cholestasis encephalopathy comorbid conditions need attention order to optimize patient outcome international life sciences institute introduction its failure accurately predict approximately ofpote...

no reviews yet
Please Login to review.