NUTRITION AND LIVER

DISEASE

Dr. dr. Joko Wahyu Wibowo, MKes

 Catabolism of hormones Glucose homeostasis;
and other serum proteins glycogenolysis & gluconeogenesis

CHRONIC LIVER
DISEASE
Synthesis:
- Albumin
- Coagulation factors
Storage:
Bile excretion - Glycogen
- Iron
- Cu, Iron, vitamins

K AT H A R I N E B R O W N
 FUNCTIONS OF THE LIVER
 Major role of the liver is the regulation of solut
es in the blood that affect the functions of othe
r organs for example: the brain, heart, muscle
and kidneys
 Strategically placed such that all blood passing
from the small intestine must travel through th
e liver
 ROLE OF THE LIVER IN NUTRIENT METABO
LISM

Carbohydrate
 Storage of carbohydrate as glycogen
 Gluconeogenesis
 Glycogenolysis
 ROLE OF THE LIVER IN NUTRIENT
METABOLISM
Protein
 Synthesis of serum proteins e.g. albumin
 Synthesis of blood clotting factors
 Formation of urea from ammonia
 Oxidation of amino acids
 Deamination or transamination of amino aci
ds
 ROLE OF THE LIVER IN NUTRIE
NT METABOLISM
Fat
 Hydrolysis of triglycerides, cholesterol and phosph
olipids to fatty acids and glycerol
 Formation of lipoproteins
 Ketogenesis
 Fat storage
 Cholesterol synthesis
 Production of bile necessary for digestion of dietar
y fat
 ROLE OF THE LIVER IN NUTRIENT
METABOLISM
Vitamins
 Site of the enzymatic steps in the activation of vitamin
s : thiamine
pyridoxine
folic acid
vitamin D(25 hydroxycholecalciferol)
 Site of the synthesis of carrier proteins for vitamins: A,
B12, E
 Storage site for fat soluble vitamins A, D, E, K, B12
Minerals
 Storage site for copper, iron and zinc
FUNCTIONS OF THE LIVER
 Storage and metabolism of macronutrien
ts such as protein, carbohydrates and lipi
ds
 Metabolism of micronutrients – vitamins
and minerals
 Metabolism and excretion of drugs and t
oxins – endogenous and exogenous
METABOLISME CARBOHYDRATE
 the liver can then release glycogen t
o muscles for energy during periods
of fasting or exercise.
 Although the liver can store conside
rable amounts of glycogen, it is the f
irst energy source used during perio
ds of prolonged fasting or caloric de
privation, and it can be depleted rap
idly.
 After glycogen the body taps other
energy sources  including protein
and fat.
 PROTEIN METABOLISM:

 We take in dietary protein from dairy product

s, produce, and meats.
 Enzymes produced by the pancreas and intesti
ne break down the protein into its amino acid
s and small peptides.
 The intestine rapidly absorbs the amino acids
with specific transport systems within its linin
g cells and then delivers the amino acids to th
e liver via the portal vein.
 When they reach the liver, they are used for e
nergy or synthesized new proteins.
 The newly synthesized proteins perform speci
fic body functions.
FAT METABOLISM:

In general, fats are neutral lipids (triglyceri

des), acidic lipids (fatty acids), and sterols
(cholesterol, plant sterols).
Triglycerides (dairy products, meats, oils, b
utter, margarine) are the most common t
ype of dietary fat and represent a major s
ource of energy.
The liver is uniquely suited to regulate and
process triglycerides.
FAT METABOLISM CONT’D………..

Dietary triglyceride is digested in the inte

stine by lipase an enzyme secreted by t
he pancreas in response to meals.
Bile secreted by the liver, makes the diges
ted fat soluble and promotes its absorp
tion.
Absorbed fat is then repackaged and tran
sported into blood, where the liver ulti
mately removes it from the circulation.
FAT METABOLISM CONT’D……………..

Fat that reaches the liver is processed in three wa

ys:
(1) stored as fat droplets in liver cells,
(2) metabolized as a source of energy,
(3) repackaged, secreted back into blood, and deli
vered to other cells in the body.
The liver is also intimately involved with the proce
ssing of dietary cholesterol and is the main sou
rce of newly synthesized cholesterol in the bod
y.
Liver disease may be associated with both high or
low blood cholesterol levels.
In general, as liver disease progresses in patients
with hepatitis C, the blood level of cholesterol d
rops.
 BILE

The liver produces and secretes a fluid (bile

) that enters the intestine to aid in digesti
on and absorption.
Bile is clear yellow to golden-brown and co
ntains water, electrolytes (salts), choleste
rol, bile salts (detergents), phospholipids,
and proteins.
Bile helps to activate enzymes secreted by t
he pancreas and is essential for the digest
ion and absorption of fat or fat-soluble vi
tamins.
 VITAMINS:
 The liver plays a role in several steps of vitamin metab
olism... Vitamins are either fat-soluble (Vitamins A, D,
E, and K) or water-soluble (Vitamin C and the B-compl
ex vitamins).
 Patients with advanced liver disease may become defi
cient in water-soluble vitamins, but this is usually due
to inadequate nutrition and poor food intake. Vitamin
B12 storage usually far exceeds the body's requireme
nts; deficiencies rarely occur due to liver disease or liv
er failure.
 When dietary intake drops, however, thiamine and fol
ate commonly become deficient. Oral supplementatio
n is usually need to restore thiamine and folate stores
to the normal range.
 VITAMINS………….
Fat-soluble vitamins require not only adequate dietary int
ake but also good digestion and absorption by the bod
y.
Bile in the gut is required for the absorption of fat-solubl
e vitamins into the body because these vitamins are rel
atively insoluble in water.
Bile acts as a detergent, breaking down and dissolving the
se vitamins so they may be properly absorbed.
Poor production of bile: oral supplementation of vitamins
A, D, E, and K may not be sufficient to restore vitamin l
evels to normal. The use of a detergent-like solution of
liquid vitamin E (TPGS) improves the absorption of vita
min E in patients with advanced liver disease. The same
solution may also improve the absorption of vitamins A
, D, and K if the latter are taken simultaneously with th
e liquid vitamin E.
Signs of CLD
NUTRITION FOR PEOPLE WITH CIRRHOSIS
At this stage the diet is generally high in compl
ex carbohydrates (breads, cereals, grains, legumes,
dried beans and peas, pasta, rice). These foods are im
portant because they provide our bodies fuel source
called blood glucose (also referred to as "blood sugar
").
During cirrhosis, individuals frequently experience low
blood sugar (hypoglycemia) or high blood sugar (h
yperglycemia).
Body is better able to maintain a healthy, sustained leve
l of energy from complex carbohydrates ("starches
") rather than from simple carbohydrates ("sugars").
 Carbohydrat......
 Sugars found in candy, fruits, sweet pastries, a
nd milk products body uses it quickly.
 The result is that energy level usually rises an
d then falls too quickly with sugars than it wo
uld with complex carbohydrates, especially th
ose with higher fiber content.
 Simple sugar foods only in smaller proportion
to complex carbohydrates and in more contro
lled portions.
 PROTEIN DIET

Protein is needed for repair and maintenance

of blood and body tissues, including liver tis
sue.
Persons with cirrhosis tend to better tolerate t
he protein from dairy and plant sources tha
n from meat sources, and therefore may ben
efit from a more vegetarian type diet.
Daily protein needs in grams will vary accordi
ng to nutritional state and the status of dise
ase.
 LIPID DIET

Use of a special prescription type of fat called

MCT oil is sometimes necessary.
MCT (medium-chain triglycerides) does not re
quire bile for absorption into the blood stre
am, so is advantageous when the liver can n
o longer produce adequate bile for digestio
n and absorption of dietary fat (lipid).
MCT can be used in place of other fats in cooki
ng and some recipes and is also available in
certain types of liquid nutritional drinks.
Persons with cirrhosis often begin to experienc
e difficulty digesting and absorbing fat in the
diet.
The result is steatorrhea, and thereby may requi
re dietary fat modification.
Fatty liver is also a condition that can occur whi
ch is the accumulation of fat in the liver.
In either of these cases, reducing the fat to 25%
of total calories (about 40-70 grams of fat dai
ly) is recommended.
 Vitamin deficiencies can occur during this stage of the
disease.
 Fat-soluble vitamins A, D, E, and K may need to be tak
en in their water-soluble form
 Deficiencies of the minerals zinc, calcium, and magnes
ium can also occur during cirrhosis and may require s
upplementation.
 Sodium typically needs to be restricted with cirrhosis.
 Considering that the person with cirrhosis must usuall
y limit sodium to 2,500 milligrams per day,
 sodium acts like a "sponge" in the body and can cause
to more fluid, predisposing abdominal fluid retention
seen in cirrhosis called ascites.
 PROTEIN AND HEPATITIS C
 Proteins are the major building blocks that the body us
es to make body components such as muscles, hair, nai
ls, skin, and blood. Proteins also make up important pa
rts of the immune system called antibodies, which help
fight off disease.
 Someone with liver damage such an approach to nutrit
ion can actually be downright dangerous. The trouble i
s that a damaged liver cannot process as much healthy
liver.
 when a damaged liver gets unduly overloaded with pro
tein, encephalopathy ( a state of mental confusion that
can lead to coma) may occur
 Diets high in protein have been demonstrated to enha
nce the activity of the cytochrome P450 enzyme syste
m, which is responsible for drug metabolism. This enha
nced activity increases the likelihood that a drug may b
e converted into a toxic byproduct capable of causing l
iver injury.
 Protein intake must be adjusted in accordance with a p
erson's body weight and the degree of liver damage pr
esent.
 Approximately 0.8 grams of protein per kilogram (2.2
pounds) of body weight is recommended in the diet ea
ch day for someone with stable liver disease.
 People with unstable liver disease or decompensated ci
rrhosis need to lower the percentage of protein conten
t in their diets so that it falls between approximately 1
0 to 15 %.
 Eat only vegetable sources of protein.
 A diet high in animal protein ( which typically contains
a lot of ammonia) may precipitate an episode of encep
halopathy among these people. Vegetarian diets, on th
e other hand, have a low ammonia content and have b
een shown to be much less likely than animal protein d
iets to induce encephalopathy.
Alcoholic liver disease is the most common type o
f CLD
Treatment of ALD is mostly supportive with treat
ment of the complications; optimising nutrition
and fluid balance
In Wilson’s disease copper accumulates in the live
r and CNS
In HH iron accumulates in the liver, skin, joints, pi
tuitary, adrenals, pancreas, heart etc.
Liver transplant is usually the only cure in chronic
liver disease
 SYARAT-SYARAT DIIT PADA PENYAKIT HATI:

1. Tinggi kalori, tinggi karbohidrat, lemak sedang,

protein disesuaikan dengan tingkat keadaan klin
ik penderita.
• Diit diberikan secara berangsur, disesuaikan denga
n nafsu makan penderita dan toleransi penderita te
rhadap protein.
2. Cukup mineral dan vitamin
3. Rendah garam/ cairan dibatasi bila ada ascites.
4. mudah dicerna dan tidak merangsang
5. bahan makanan yang menimbulkan gas dihindar
kan
MACAM DIIT DAN INDIKASI PEMBERIAN
Diit Hati I:

 Penderita cirrhosis hepatis berat, dan penderita hep

atitis infeksiosa akut dalam keadaan prekoma atau se
gera sesudah penderita dapat makan kembali
 Berupa cairan yang mengandung KH sederhana : sa
ri buah, sirop, teh manis.
 Bila tak disertai ascites cairan diberikan kurang lebi
h 2 liter/ hari, bila ada ascites dan diuresis belum se
mpurna : cairan maksimum 1 liter/ hari.
 Rendah kalori, protein, kalsium, besi, thiamin
 Sebaiknya tidak diberikan lebih dari 3 hari
 Untuk menambah kalori bisa diberikan infus glukos
a
BAHAN MAKANAN YANG DIBERIKAN
Sari buah 1000 g 5 gls
Sirop 400 g 2 gls
Gula pasir 100 g 10 sdm
Nilai gizi:
Kalori 1025 besi 9,3 mg
Protein 7 g vit. A 2775 SI
Lemak 1 g thiamin 0,6
mg
KH 247 g vit.C 635 mg
Kalsium 0,2 g natrium 31,4
mg
PEMBAGIAN MAKAN SEHARI
Pukul 07.00 teh manis 1 gls
Pukul 08.00 sari pepaya 1 gls
Pukul 10.00 air jeruk 1 gls
Pukul 12.00 sari pepaya 1 gls
sirop 1 gls
Pukul 15.00 air jeruk 1 gls
Pukul 18.00 sari pepaya 1 gls
sirop 1 gls
Pukul 20.00 teh manis 1 gls
DIIT HATI II
• Bila keadaan akut/ prekoma sudah diatasi
• Penderita sudah mempunyai nafsu makan
• Diberikan dalam bentuk cincang/ lunak
• Protein dibatasi 30 g/ hari
• Lemak yang mudah dicerna
• Rendah kalori, kalsium, besi dan thiamin sebaiknya di
berikan beberapa hari saja.
• Bila ada ascites hebat, diuresis belum baik : diberikan
diit rendah garam I
BAHAN MAKANAN YANG DIBERIKAN
 Beras 120 g 4 gls bubur nasi
 Maezena 20 g 4 sdm
 Daging 50 g 1 ptg sedang
 Telor 25 g ½ butir
 Sayuran 200 g 2 gls
 Buah 300 g 3 ptg pepaya sedang
 Gula pasir 100 g 10 sdm
 Margarin 25 g 2 ½ sdm

Nilai gizi :
Kalori 1475 besi 9,3 mg
Protein 27 g vit.A 8892 SI
Lemak 30 g thiamin 0,5 mg
KH 278 g vit.C 170 mg
Kalsium 0,2 g natrium 360 mg
DIIT HATI III

• Sebagai makanan perpindahan dari diit hati II

• Penderita dengan nafsu makan cukup
• Diberikan dalam bentuk lunak/ biasa
• Protein diberikan 1 g/ kgBB/hari
• Lemak sedang dalam bentuk yang mudah dicerna
• Cukup kalori, besi, vitamin A dan vitamin C, kurang k
alsium dan thiamin
• Bila ada retensi cairan/ ascites berikan rendah garam
• Bila ascites hebat/ diuresis belum baik berikan RG I
BAHAN MAKANAN YANG DIBERIKAN
berat (g) urt
 Beras 250 5 gls tim
 Maezena 20 4 sdm
 Daging 100 2 pt sdg
 Telur 25 ½ butir
 Tempe 50 2 pt sdg
 Sayuran 200 2 gls
 Buah 300 3 pt pepaya sdg
 Minyak 25 2 ½ sdm
 Gula pasir 60 6 sdm

Nilai gizi :
 Kalori 2013 besi 16,6 mg
 Protein 54 g vit.A 8432 SI
 Lemak 46 g thiamin 0,8 mg
 KH 349 g vit.C 170 mg
 Kalsium 0,3 g natrium 233 mg
DIIT HATI IV

• Makanan perpindahan dari diit hati III

• Pada penderita hepatitis infeksiosa dan cirrhosis hepa
tis yang nafsu makannya baik, dapat menerima prote
in, tidak menunjukkan gejala cirrhosis hepatis aktif.
• Bentuk lunak/ biasa
• Mengandung kalori tinggi, protein tinggi,lemak cuku
p,KH tinggi, vitamin dan mineral cukup.
• Bila ada retensi air berikan rendah garam ( diit hati IV
rendah garam).
• Bila ascites hebat dan tanda-tanda diuresis belum bai
k berikan RG I.
MAKANAN YANG DIBERIKAN
berat (g) urt
Beras 350 5 gls nasi
Daging 100 2 pt sdg
Telur 100 2 butir
Tempe 100 4 pt sdg
Kacang hijau 25 2 ½ sdm
Sayuran 200 2 gls
Buah 200 2 pt pepaya sdg
Minyak 25 2 ½ sdm
Gula pasir 40 4 sdm
Susu 200 1gls

Nilai gizi :
Kalori 2554 besi 28,0 mg
Protein 91 g vit.A 9176 SI
Lemak 64 g thiamin 1,3 mg
KH 404 g vit.C 133 mg
Kalsium 0,7 g natrium 414 mg
BAHAN MAKANAN YANG TIDAK BOLEH DIBERI
KAN

Sumber lemak : semua makanan dan daging yang bany

ak mengandung lemak: seperti daging kambing, babi
.
Bahan makanan yang menimbulkan gas : ubi, kacang m
erah, kol, sawi, lobak, ketimun, durian, nangka.
Cara memesan diit : diit hati I/II/III/IV Rendah garam I/I
I/III ( DH I/II/III/IV RG I/II/III)
PENYAKIT KANDUNG EMPEDU
Kolesistitis peradangan kandung empedu disebabkan oleh
penyumbatan saluran empedu oleh batu empedu
Gejala: nyeri pada seperempat bagian atas perut, mual, mu
ntah, kembung, ikterus
Pengobatan: analgetik, antiemetik, kolesistektomi dan drai
nase duktus biliari
Penatalaksanan gizi
1. Intervensi: kurangi rangsangan kandung empedu (ren
dah lemak atau tidak sama sekali), suplementasi (vita
min A dan E larut dalam air
2. Pendidikan pasien: pembatasan diet dan rasionalisasi
SYARAT-SYARAT DIET PADA PENYAKIT KANDU
NG EMPEDU
1. Rendah lemak untuk mengurangi kontraksi kandung
empedu, diberikan dalam bentuk mudah dicerna.
2. Kalori, protein, KH : cukup, bila terlalu gemuk jumlah
kalori dikurangi.
3. tinggi vitamin terutama yang larut dalam lemak.
4. mineral cukup
5. cairan banyak untuk membantu pengeluaran kuman-
kuman atau sisa-sisa metabolisme dan mencegah
dehidrasi.
6. tidak merangsang dan diberikan dengan porsi kecil
tetapi sering untuk mengurangi rasa kembung
MACAM DIIT DAN INDIKASI PEMBERIAN

DIIT RENDAH LEMAK I

1. Untuk penderita cholecystitis akut dan cholelithiasi
s dengan kolik akut.
2. Diberikan berupa buah-buahan dan minuman mani
s
3. Rendah kalori dan semua zat-zat kecuali vitamin A
dan C
4. Sebaiknya diberikan selama 2-3 hari
BAHAN MAKANAN YANG DIBERIKAN SEHARI
berat (g) urt
 Buah 1000 10 pt pepaya sedang
 Sirop 400 2 gls
 Gula pasir 100 10 sdm

Nilai gizi :
 Kalori 996 besi 17 mg
 Protein 5 g vit.A 3650 SI
 Lemak 0 g thiamin 0,4 mg
 KH 244 g vit.C 780 mg
 Kalsium 0,2 g
PEMBERIAN MAKAN SEHARI
Pukul 07.00 teh manis 1 gls
Pukul 08.00 pisang 1 gls
Pukul 10.00 pepaya 2 ptg sdg
Pukul 12.00 pisang 2 bh sdg
sirop 1 gls
Pukul 15.00 pepaya 2 ptg sdg
Pukul 18.00 pisang 2 bh sdg
sirop 1 gls
Pukul 20.00 pisang 1 ptg sdg
teh manis 1 gls
BAHAN YANG DIBERIKAN SEHARI
berat (g) urt
 Beras 100 3 gls bubur nasi
 Daging 100 2 pt sdg
 Telur 50 1 butir
 Tempe 100 4 pt sdg
 Sayuran 200 2 gls
 Buah 400 4 pt pepaya sdg
 Margarin 10 1 sdm
 Gula pasir 30 3 sdm

Nilai gizi :
 Kalori 1338 besi 21,8 mg
 Protein 57 g vit.A 9138 SI
 Lemak 33 g thiamin 0,8 mg
 KH 211 g vit.C 211 mg
 Kalsium 0,4 g
DIIT RENDAH LEMAK III

Untuk penderita penyakit kandung empe

du yang tidak gemuk dan cukup memp
unyai nafsu makan.
Dalam bentuk lunak/ biasa
Cukup kalori dan semua zat gizi
BAHAN MAKANAN YANG DIBERIKAN SEHARI
Beras 250 5 gls nasi tim
Maezena 20 4 sdm
Daging 100 2 pt sdg
Telur 50 1 butir
Tempe 100 4 pt sdg
Sayuran 250 21/2 gls
Buah 200 2 pt pepaya sdg
Margarin 10 1 sdm
Gula pasir 80 8 sdm
Susu skim 20 4 sdm

Nilai gizi :
Kalori 2073 besi 21,8 mg
Protein 74 g vit.A 10473 SI
Lemak 34 g thiamin 0,9 mg
KH 369 g vit.C 143 mg
Kalsium 0,7 g
 BAHAN MAKANAN YANG TIDAK BOLEH DIBERIK
AN
Sumber lemak : semua makanan yang digoreng
semua makanan/daging yang mengandung lemak tinggi : may
onais, daging kambing, dan babi.
Bahan makanan yang menimbulkan gas : ubi, kacang merah,
kol, sawi, lobak, durian, nangka, mentimun.
Bumbu yang merangsang : cabe, bawang,merica, asam, cuka,
jahe.
Minuman yang mengandung soda dan alkohol.
PENATALAKSANAAN PANKREATITIS
 Pengobatan: antikolinergik seperti atropin, anti nyeri
 Penatalaksanaan gizi:
1. Penilaian gangguan
2. Intervensi:
 Hindari perangsangan sekresi pankreas dan penyebab ny
eri selama pankreatitis akut (TPN). Nyeri berkurang beri ca
iran, rendah lemak, tinggi karbohidrat, diet bertahap.
 Rangsang penyembuhan dan modifikasi diet untuk kompe
nsasi penurunan sekresi pankreatik pada pankreatitik aku
t. Tinggi protein, tinggi karbohidrat, lemak sesuai tolerans
i. Minyak MCT Medium Chain Triglyceride), enzim pankrea
s, sekresi insulin terganggu
 Pendidikan pasien (pembatasan diet dan rasionalisasi),
 Hindari minuman beralkohol
HEPATITIS
Hepatitis adalah radang hati
Penyebab: virus, toxin, obstruksi, parasit, o
bat-obat (alkohol, kloroform, karbon tetr
aklorida)
Lab: peningkatan kadar bilirubin serum, as
partat aminotransferase (AST0, atau SGO
T), alanin aminotransferase (ALT, atau SG
PT), dan laktat dehidrogenase (LDH)
Pengobatan: penyebab dihilangkan, istirah
at dan terapi gizi pengobatan utama
PENATALAKSANAAN GIZI PADA HEPATITIS
 Penilaian gangguan
 Intervensi:
1. Promosi regenerasi hati: tinggi kalori, tinggi pro
tein, sedang lemak, karbohidrat sumber kalori u
tama, makanan sering tapi porsi kecil
2. Suplementasi: bila stetorea diberi suplemen vita
min A, E dalam bentuk larut dalam air
 Pendidikan pasien
1. Modifikasi diet dan rasionalisasinya: tinggi prot
ein, rendah lemak
2. Hindari alkohol
PENATALAKSANAAN SIROSIS DAN ENSEFALO
PATI HEPATIK
 Pengobatan: laktulosa menurunkan amonia
 Penatalaksanaan gizi:
1. Penilaian gangguan
2. Intervensi:
 Hindari perangsangan atau perlakuan yang memper
hebat ensepalopati, sementara menyediakan diet pa
ling bergizi (tinggi kalori 45-50kkal/kg, lemak mode
rat 70-100g kecuali steatorea, MCT , protein dibatasi
1-1,5 g/kg, pada ensepalopati dibatasi 0,5 g/kg mak
simum 1 g/kg, protein nabati lebih ditoleransi, Asa
m Amino Rantai Cabang (BCAA), Natrium dibatasi
 Dorong kenyamanan dan toleransi pemberian maka
nan (porsi kecil tapi sering)
 Cegah perdarahan varises esofagus (makanan lembu
t rendah serat)
 Suplemen 2-3 kali RDA vitamin B kompleks
ACUTE HEPATITIS:
High protein/high energy intake required to promote h
epatocyte regeneration
Fat restriction contraindicated
Nausea/anorexia
Consider oral supplementation such as glucose polymers,
fruit based high protein drinks, or high protein/ high ener
gy drinks in the presence of nausea/anorexia
Caution against herbal remedies as some may be harmf
ul and most have no scientific basis
NUTRITIONAL MANAGEMENT OF END ST
AGE LIVER DISEASE
Energy Requirements:
 Patients with compensated cirrhosis do not appear to n
eed modification of their energy intakes
 Patients with decompensated liver disease require 35 –
40 non protein kcals/kg/day*
 Ascites is a viable metabolic unit
NUTRITIONAL MANAGEMENT OF END ST
AGE LIVER DISEASE
Protein
 Protein turnover in cirrhotic patients is norma
l or increased
 Stable cirrhotics have increased protein requi
rements
 Stable cirrhotic patients are capable of achiev
ing positive nitrogen balance during aggressi
ve nutritional support regime

¹Kondrup J, Neilsen K et al. Effect of long term refeeding on protein metabolism in patients wi
th cirrhosis of the liver. Br J Nutr 1997; 77: 197-212
²Swart, GR et all. Minimal protein requirements in liver cirrhosis determined by nitrogen balan
ce measurements at three levels of protein intake. Clin Nutr 1989; 8: 329-336
PREVALENCE AND IMPLICATIONS OF MALNUTRITION AN
D SARCOPENIA IN CIRRHOSIS
Malnutrition is a frequent burden in cirrhosis
 In 20% of patients with compensated cirrhosis
 In >50% of patients with decompensated cirrhosis1
Progression of malnutrition is associated with prog
ression of liver failure
 May be less evident in compensated cirrhosis
 Easily recognizable in patients with decompensated
cirrhosis
Both adipose tissue and muscle tissue can be deple
ted
 In female patients, depletion of fat deposits is more
frequent
 In men, loss of muscle tissue is more rapid1,2
PREVALENCE AND IMPLICATIONS OF MALNUTRITION AND SARCOP
ENIA IN CIRRHOSIS....................
Malnutrition and muscle mass loss (sarcopenia), which is ofte
n used as an equivalent of severe malnutrition,1 associate
with complications:2
 Susceptibility to infections
 Hepatic encephalopathy
 Ascites
 Independent predictors of lower survival in cirrhosis and in pat
ients undergoing liver transplantation
Malnutrition and sarcopenia should be recognized as complic
ations of cirrhosis that worsen the prognosis of patients
 General agreement that these patients’ dietary intake needs t
o improve
 Whether malnutrition can be reversed in patients with cirrhosi
s is unclear
SCREENING FOR MALNUTRITION IN CIRRHOSIS
As malnutrition is associated with worse prognosis, all patien
ts with advanced chronic liver disease, especially decompe
nsated cirrhosis, should undergo a rapid nutritional screen
Two criteria stratify patients at high risk of malnutrition:
 Being underweight (BMI <18.5 kg/m2)
 Advanced decompensated cirrhosis (Child–Pugh C)

All patients at risk of malnutrition should undergo detailed n

utritional assessment by a registered dietician or nutrition
expert
NUTRITIONAL MANAGEMENT PRINCIPLES IN CIRRHOSIS:
ENERGY AND PROTEIN REQUIREMENTS

Cirrhosis is a state of accelerated starvation characterized by

a rapid post-absorptive physiology and reduced respirator
y quotient
 Protein synthesis is decreased and gluconeogenesis from ami
no acids increased, necessitating proteolysis, which contributes
to sarcopenia
Energy supply needs to balance total energy expenditure (TE
E)
 Most interventions aim for ≥35 kcal/kg.BW/day*
Optimal daily energy intake should not be lower than the recom
mended
35 kcal/kg actual BW/day (in non-obese individuals)
Optimal daily protein intake should not be lower than the recom
mended
1.2–1.5 g/kg actual body weight/day
PRACTICAL ADVICE FOR PATIENTS
Healthy eating of a variety of foods is advisable for all patien
ts
With the exception of alcohol, virtually no food damages the
liver and is genuinely contraindicated in patients with chr
onic liver disease
In most cases eating adequate calories and protein is much m
ore important than avoiding specific types of food
 It is important that patients have a good, varied diet that they
enjoy
Food intake should be split
 Three main meals: breakfast, lunch and dinner
 Three snacks:
 Mid-morning, mid-afternoon, late evening
 Late-evening snack is the most important
 MECHANISMS RESULTING IN SARCOPENIA AND FAILURE TO RESPO
ND TO STANDARD SUPPLEMENTATION

Anabolic resistance and dysregulated proteostasis result in sarcopenia and/or failure t

o respond to standard supplementation
These mechanisms represent potential therapeutic targets
POTENTIAL MANAGEMENT APPROACHES TO SARCOPENIA:
OTHER APPROACHES
MICRONUTRIENT
Vitamin deficiencies in liver disease are generally related to h
epatic dysfunction and diminished reserves
 Inadequate dietary intake and malabsorption increase with dis
ease severity
A majority of liver disease patients considered for liver trans
plantation present with vitamin A and D deficiencies
 Vitamin D levels <20 ng/ml are reported in chronic cholestatic
conditions, and often inversely correlate with disease severity a
nd Child–Pugh score
 Vitamin D also correlates with treatment response in HCV, NA
FLD and patients who develop HCC
NUTRITIONAL TREATMENT OPTIONS FOR
HEPATIC ENCEPHALOPATHY (HE)
HE is more common in malnourished patients with cirrhosis
 Inverse relationship between muscle mass and blood ammonia levels
Hyperammonaemia may impair muscle function and contribute to
muscle loss1
Patients with cirrhosis and HE have the same energy requirements a
s those without HE
Although dysregulated nitrogen metabolism plays a key role in HE
development, nitrogen requirements are the same as patients wi
thout HE