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15 - 1015-1115 02 ผศ.นพ.นริศร ลักขณานุรักษ์
15 - 1015-1115 02 ผศ.นพ.นริศร ลักขณานุรักษ์
NUTRITION SUPPORT IN
LIVER DISEASE
Narisorn Lakananurak MD. MSc.
Physician Nutrition Specialist
November 24, 2021
2018 2019 2021
Diagnosis
Severity
Causes
80
60 Mild PEM
Moderate PEM
40 Severe PEM
20
0
Child A Child B Child C
46.2% 84.1% 94.6%
Arq Gastroenterol 2006; 43(4): 269–74
POOR OUTCOMES
100 100
90
80 80 64.6
65
70
60 60 47.8
50
40 40
20 30
11 14.1
20 20 7.5 5.12.8
0 10
0 0
1 yr Mortality Complications Mortality Ascites HRS
Malnourished Malnourished
Wellnourished Wellnourished Nutrition 2005; 21: 113–7
Liver Int. 2009; 29(9): 1396-402
Sarcopenia
2X
2.5X
decompensation
1.6X
4.6X
Clin Gastroenterol Hepatol. 2012 Feb;10(2):166-73
JHEP Rep. 2019 Dec 5;2(1):100061.
- Perform a rapid nutrition screen in - Liver disease patients should be All patients with cirrhosis
Who All patients with cirrhosis screened for malnutrition using a
validated tool.
- High risk: BMI <18.5 kg/m2, Child- - The Best Option: RFH-NPT - Most consistent tool: RFH-NPT
How Pugh C, Use nutritional screening - Others: NRS 2002
tools in all other instances.
- Liver disease specific tools: RFH-
NPT, The liver disease
undernutrition screening tool
(subjective, low NPV)
- Others: not validated, bias from
fluid retention
Topics EASL 2018 ESPEN 2019 AASLD 2021
grip
- CT/MRI when available, insufficient data for a
bedside tool
ที่
วั
ห้
รื
Nutrition
Screening: Nutrition
- BMI <18.5kg/m2
All - Child C Assessment
- Positive nutrition - Tools: SGA, RFH-GA,
Cirrhosis screening tools (RFH- others
Patients NPT, others: beware - Dietary assessment
fluid overload) (+time and meal
number)
& Obesity
evaluation
Sarcopenia
evaluation
- CT/MRI at L3 if
available
- DEXA, BIA, MAMC,
MAMA
- Handgrip, SPPB
Sarcopenia Criteria
Variables Measurements Gender AWGS JSH AWGS
2014 2015 2019
CT/MRI Male ≤42 cm2/m2
(L3 level)
Female ≤38 cm2/m2
- A tailored, moderately hypocaloric (- - Lifestyle intervention for weight - BMI 30-40 kg/m2: 25-35 kcal/kg/day
Obese 500-800 kcal/day) diet to achieve weight reduction (reduced portal - BMI >40 kg/m2: 20-25 kcal/kg/day
loss. hypertension) ใ idea BW (non-hospitalized, clinically stable)
- 25 kcal/kgIBW/day - Weight loss under supervision (caution
บ แ ง ระยะ น อง ลด BW in decompensated cirrhosis)
ง ไ ประ โยน
จะ
หั
ถ้
ค่
ดูว่
ก็
อี
ตั
จึ
ต้
ต้
ป็
ห้
ด้
ข่
ม่
ล้
ช้
ข็
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Topics EASL 2018 ESPEN 2019 AASLD 2021
- Administer micronutrients and vitamins - Micronutrients should be administered to treat - Micronutrient deficiencies should be assessed at
to treat confirmed or clinically suspected deficiency. confirmed or clinically suspected deficiency least annually, repleted if deficient, and
- Assess vitamin D levels in cirrhotic patients, as - Reported deficiency reassessed after repletion.
deficiency is highly prevalent and may adversely Vitamin: D, B1, Fat soluble (cholestasis) - Pragmatic approach: empiric course of
จะ เส ม เ อ
affect clinical outcomes. diniccil Trace elements: Zn, Se multivitamin supplementation in malnutrition,
frailty, or sarcopenia.
- Reported deficiency ขาด เ า น - Pragmatic approach: liberal supplementation in
- In patients who cannot meet nutrition target from
Vitamin: A, K (cholestasis), B1 the first 2 weeks of nutritional support
sodium-restricted diet, liberalization of sodium
Trace element: Zn, Se, Fe - Ascites: Moderate sodium diet (usually 60
restriction should be considered.
Toxicity: Mn (avoid supplement with Mn) mmol/day = 1,400 mg/day) but should balance
- Pragmatic approach: course of multivitamin against lower food consumption.
supplementation in decompensated patients.
- Ascites: Sodium restriction 2,000 mg/day – should
not below 1,400 mg/day, take care about diet
palatability.
- Evaluate BMD in cirrhosis, cholestasis, long-term
steroid, before LT (Lumbar and femoral DEXA)
- Osteoporosis/penia: Calcium 1,000-1,500 mg/day
and Vitamin D 400-800 IU/day + Bisphosphonate
(Osteoporosis)
มี
นั้
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Topics EASL 2018 ESPEN 2019 AASLD 2021
- Healthy eating with variety of foods - Minimize fasting time, with maximum - Minimize fasting time: 3-5 meals + late
Oral - Avoid food restriction, except alcohol interval of 3-4 hours between intake evening snack
- Minimize fasting time: frequent meals during awake + early breakfast and late
(e.g. 3 main meals + 3 snacks) with late evening snack
evening snack and breakfast
- - NG can be placed even with - NG can be placed even with
EN esophageal varices (beware after esophageal varices.
recent banding) - PEG is associated with complications
- PEG should not be placed in patients (due to ascites and varices), it can be
with ascites used in exceptional cases (mild ascites)
EASL 2018 ESPEN 2019 AASLD 2021
- Decompensated cirrhotic patients when adequate - Advanced cirrhosis to improve event-free - Not recommend beyond diverse protein source
nitrogen intake is not achieved by oral diet. survival or quality of life
- Hepatic encephalopathy to improve symptom and - In patients with protein intolerant to facilitate
reach nitrogen intake. protein intake
- Critically ill cirrhosis with HE to facilitate resolution - Hepatic encephalopathy in need of EN
EASL 2018 ESPEN 2019 AASLD 2021
- Avoid protein restriction ไ ควร restrict - Protein should not be restricted - Protein should not be restricted
- Encourage vegetables and dairy protein - Protein can be deferred for 24-48 hours - Do not recommend limiting meat-based
- Severe HE (grade III-IV): EN (protected until hyper-ammonemia is controlled in protein, encourage to consume diverse
airway) or PN severe hyper-acute HE and highly elevated protein sources, including vegetable and
ammonia (risk of cerebral edema) dairy when possible
- Vegetable protein should be used in นใ พอ อน อย แนะ ใ น Plant protein
ห อ dairy product
patients with protein intolerant
Preoperative Preoperative -
- Goal 30 kcal/kg/day and Protein 1.2 - Goal 30-35 kcal/kg/day and Protein 1.2-
g/kg/day (maintain nutrition), 35 kcal/kg/day 1.5 g/kg/day (non-obese), 25
and Protein 1.5 g/kg/day (improve nutrition), kcal/kgIBW/day and Protein 2-2.5
25 kcal/kg/day and Protein 2 g/kg/day g/kgIBW/day (obese)
(obese) - No role BCAA-enriched and immune-
- No role BCAA-enriched and immune- enhancing in adults
enhancing in adults Postoperative
Postoperative - Early oral/EN within 12-24 hours
- Early oral/EN within 12-24 hours - EN with selected probiotics (Lactobacillus
- Can use ERAS protocol sp.) can be used to reduce infection
- After acute phase: goal 35 kcal/kg/day and - After acute phase: same goal as
Protein 1.5 g/kg/day preoperative
Nutrition
Screening: Nutrition Nutrition
- BMI <18.5kg/m2
All - Child C Assessment Management
- Positive nutrition - Tools: SGA, RFH-GA, - Energy,
Cirrhosis screening tools (RFH- others Macronutrients,
Patients NPT, others: beware - Dietary assessment Micronutrients
fluid overload) (+time and meal - Route
number) - Others
& Obesity
evaluation
Sarcopenia
evaluation
- CT/MRI at L3 if
available
- DEXA, BIA, MAMC,
MAMA
- Handgrip, SPPB
BW Energy Oral & ONS
- No ascites: Actual BW - IC when possible - Limited fasting time: Frequent
- Ascites: estimated dry - 30-35 kcal/kg/day meal (4-6 meals) + Late evening
weight or IBW snack and Early breakfast
Protein
- 1.2-1.5 g/kg/day
- No restriction even in HE (except short
EN
Nutrition period in severe, acute HE) - NG: EV is not contraindication.
- PEG: Beware in
Management - Diverse protein types, may prefer
vegetable/dairy in HE ascites/varices
Micronutrients
- Vitamin D level
PN
- Consider a course of MTV (e.g. 2 wks) in
Obesity
malnutrition, inadequate intake
- Consider weight reduction
5-10% esp. in compensated
- Low Na in ascites, consider food BCAAs
palatability - Decompensated cirrhosis with
cirrhosis
- BMD with Ca (1-1.5 g/d) and Vitamin D inadequate protein intake
- Hypocaloric, High protein
in osteoporosis/penia
(25 kcal/kgIBW/d + 1.5-2.5 - Protein intolrance
- Consider: AEK (esp. cholestasis), B1,
g/kgIBW/d)
Zn, and Avoid Mn supplementation
- May HE
source เ น
diverseprotein Stline
1
dose 0.25 glhgd