Katie Grabow

MAJOR CASE STUDY March 28, 2019

Decatur Memorial Hospital
 © 2014 Pearson Education, Inc.

LIVER CIRRHOSIS
(a) A healthy liver (b) A liver with cirrhosis
•What is cirrhosis?
• Chronic disease of the liver due to chronic injury (degeneration of liver cells and tissue thickening).

Alcohol metabolism Inability to oxidize Fatty accumulation in the

reduces NAD+ to NADH + macronutrients via TCA liver
H+ cycle

Causes: Symptoms:
•Alcohol abuse •Edema
•Hepatitis B-D •Jaundice
•Obesity with NAFLD •Weight loss
•Fatigue
•Decrease in appetite
 MNT- CIRRHOSIS
•Energy: 30-35 kcals/kg
• Catabolic state

•Carbohydrates: 50% kcals

• Due to lack of hepatic glycogen stores

•Protein: 1-1.5 g/kg

• Liver protein synthesis impaired (decreased albumin ascites and edema)
• Plant based sources (BCAAs) zinc deficiency

•Fat: Accelerated use of fat as fuel, as glycogen stores quickly depleted.

• Malabsorption of fat (Fat soluble vitamin deficiencies)
• Omega 3s

•4-6 small meals/day

•Ascites: Low Na+ diet and potentially a fluid restriction
 Cirrhosis & Malnutrition:

Decreased PO intake
• Early satiety-ascites
• Decreased appetite
• Kcals from alcohol
• Dietary restrictions

Malabsorption/ Maldigestion
• Increased protein breakdown
• Decreased liver production and
storage
• Decreased fat absorption
• Glucose intolerance/insulin resistance
• Damage to gastric mucosa and jejunal
villi
• Lactulose use
EN/PN FOR CIRRHOSIS
•EN preferable over PN
• cheaper, decreased risk of infection, preservation of gut mucosa
• Side effect of PN may be liver damage

•Formulas containing glutamine not recommended

•BCAAs
•Pt with ascites Concentrated high-energy formula preferred in order to avoid
positive fluid balance
MEDICAL TREATMENT
•TIPS: a shunt added to connect the portal vein to hepatic vein
•?Protein restriction post-TIPS in cases of high risk for HE
•Liver Transplant:
•MNT prior to liver transplant:
• 30-35 kcals/kg
• 1.5- 2 g of protein/kg
• EN-BCAA enriched
•MNT post-liver transplant:
• 30-35 kcals/kg
• 1 g protein/kg
• Multivitamin
PATIENT INFORMATION
•Name: P.C.
•Age: 67
•Gender: Male
•Weight at Admit: 172 lbs
•Height: 185.4 cm (6’1”)
•BMI: 21.84 kg/m²
•Date of Admission: 3/12/19
•Unit: ICU
Weight History:
• Admit Wt: 172 lbs
• Wt at Assessment: 165 lb 8 oz
• Wt Hx: see next slide
• Wt Change: -63 lbs
• Time Period: 3 months
• Weight Loss: 28%; significant (fluid?)
 Weight History over Last Year
260

250
250
241
240 237
233
230 230
230 228
Weight in Pounds

220

210
204

200

190 187

180
172
170
165

160
22-Mar-18 22-Apr-18 22-May-18 22-Jun-18 22-Jul-18 22-Aug-18 22-Sep-18 22-Oct-18 22-Nov-18 22-Dec-18 22-Jan-19 22-Feb-19
Date
 INITIAL ASSESSMENT (3/19)
•PMH: alcoholic liver disease with cirrhosis,
ascites, HLD, CKD3, Myelodysplastic
syndrome
•Admitted for: hypotension; ascites
•Medical Diagnoses: alcoholic liver
cirrhosis, upper GI bleed (EGD 3/19),
pancytopenia, AKI on CKD3, Hepatorenal
syndrome
*Nutrition-focused physical exam deferred
as Pt is asleep post-procedure
• Subjective:
• Intentional weight loss via Natural Nutrition
program until end of June 2018
• Unintentional weight loss x3 months
• Lived on his own until 3/8 caregiver
• No longer cooks for himself (Meals on
Wheels)
• Consuming ~ 50% meals since admit (24%
EER and 18% protein needs)
• No known food allergies
• No difficulties chewing/swallowing
• Last BM 3/19
LABS & MEDS (3/19)
•Pertinent Labs: •Pertinent Meds:
• Potassium 5.3 (H) • Calcium-Vitamin D
• Creatinine 3.10 (H) • Electrolyte-R
• Total Protein 5.0 (L) • Protonix
• Glucose 131(H) • Vitamin B1
• Alkaline Phosphatase 131(H) • Vitamin D3
INITIAL DIAGNOSIS
•Inadequate protein and energy intake related to decreased ability to consume
sufficient energy secondary to lack of appetite and inability to prepare meals as
evidenced by estimates of insufficient protein and energy intake from diet
compared to estimated needs and 28% weight loss in 3 months.
• Unable to diagnose malnutrition by ASPEN criteria at this time due to lack of information.
INTERVENTION & MONITORING
•Nutrition Prescription:
• Energy Needs: dosing wt 75.1kg, 25-30 kcals/kg= 1878-2253 kcals/day
• Protein Needs: dosing wt 75. kg, 1.2-1.4 g/kg= 90-105 grams
• Fluid Needs: dosing wt 75.1 kg, 30 ml/kg= 2253 mL/day

•Intervention:
• Food and Nutrient Delivery- 2 gm Na Restricted Diet with 2 Ensure Enlive/day

•Monitoring/Eval:
• Goals: Pt to meet >75% EER and protein needs by 3/22
• Nutrition Status Classification: NS3, Follow up in 2-5 days
CHECK 3/20
•Pt alert and able to provide more subjective information
•Dietary recall:
• lack of appetite x 2-3 months
• approximately 855 kcals, 42 g protein (46% EER and 47% protein needs)

•Pt currently NPO

•Goals: Pt to advance to diet as medically able. Will send supplements at that time.
CHECK (3/20)
•Nutrition Focused Physical Findings:
• Fat Loss: Severe~ hollow depressions of orbital region, very little space between folds in upper
arms, depression between ribs apparent, iliac crest prominent
• Muscle Loss: Severe~ depression of temples, protruding clavicle bone, shoulder to arm joint looks
square, depressions between shoulder/spine, unable to assess lower extremities
• Skin: trace edema of BLE< intact, Braden score 16
• Functional Changes: generalized weakness

•New Nutrition Diagnosis:

• Severe malnutrition in the context of chronic illness related to diminished intake and increased
protein and energy needs secondary to liver cirrhosis as evidenced by >7.5% weight loss in 3
months, < 75% energy intake compared to estimated needs for > 1 month, and severe depletion
of body fat and muscle mass.
DISCHARGE AND FUTURE NUTRITION PLAN OF CARE
•Pt discharged to Barnes Jewish Hospital on 3/21
•Pt planned to have TIPS at Barnes, and remains on liver transplant list

•If I were to continue with this Pt’s nutrition plan of care, I would…
• Increased energy needs
• Would not restrict protein needs-suggest plant based protein sources
• Treat potential mineral deficiencies (B vitamins, zinc, fat soluble vitamins, magnesium)
• Monitor glucose tolerance-adjust carbohydrates as appropriate
• Diet education
REFLECTION
What did I learn?
•Obtained a better understanding of
alcoholic cirrhosis and the role of a RD in the
care process of these patients
• Refreshed my knowledge of some
metabolism and MNT concepts specific to
disease state
•Difficulties in diagnosing malnutrition by
ASPEN criteria with limited information
•Weight history accuracy
•Accuracy of nutrition risk screen
What would I have done differently?
•Assessed Pt at an early date
• Admitted 3/12, assessed 3/19?
•Increased energy needs
•Pushed for PO diet at time of check
•If I had known Pt’s future plan of care, I
could have personalized nutrition
recommendations to better fit his situation.
THANK YOU!