Nutrition and Liver Diseases

Nutrition and liver
disease
Razia Kousar
Generic BScN, MScN
Objectives
 Review the functions of the liver
 Review diseases of the liver
 Major complications of liver disease
 Nutritional features of end stage liver disease
 Nutritional management of end stage liver disease
 Nutritional response to hepatic transplantation
 Nutritional management of non alcoholic fatty liver
disease (NAFLD)
 Hepatitis C
Functions of the Liver
 Major role of the liver is the regulation of
solutes in the blood that affect the functions of
other organs for example: the brain, heart,
muscle and kidneys
 Strategically placed such that all blood

passing from the small intestine must travel
through the liver
Cont….
 Metabolism of macronutrients such as
protein, carbohydrates and lipids
 Metabolism of micronutrients – vitamins and

minerals
 Metabolism and excretion of drugs and

toxins – endogenous and exogenous
Functions of the Liver:
A Brief Overview
 Largest organ in body, integral to most metabolic
functions of body, performing over 500 tasks
 Only 10-20% of functioning liver is required to
sustain life
 Removal of liver will result in death within 24
hours
Functions of the Liver
 Main functions include:
 Metabolism of CHO, protein, fat
 Storage/activation vitamins and minerals
 Formation/excretion of bile
 Steroid metabolism, detoxifier of drugs/alcohol
 Conversion of ammonia to urea
 Gastrointestinal tract significant source of ammonia
 Generated from ingested protein substances that are
deaminated by colonic bacteria
 Ammonia enters circulation via portal vein
 Converted to urea by liver for excretion
Liver Diseases
Classifications
 Duration Viral hepatitis A, B, C, D, E (and G)
 Acute vs Chronic
 Pathophysiology
Fulminant hepatitis
 Hepatocellular vs Cholestasic
Alcoholic liver disease
 Etiology
 Viral
Non-alcoholic liver disease
 Alcohol Cholestatic liver disease
 Toxin
 Autoimmune
Hepatocellular carcinoma
 Stage/Severity Inherited disorders
 ESLD
 Cirrhosis
Nutritional Management of
Liver Disease
Early Stages of Liver Disease:
 No specific dietary management
 Healthy diet according to healthy eating

guidelines
 Beware of miracle cures

Nutritional Features of Liver
Disease
 Weight and BMI do not reflect true
nutritional status (ascites and/or oedema)
 Exhibit features of protein energy

malnutrition
Nutritional Features of End
Stage Liver Disease
 Look malnourished
 Low protein levels
albumin, prealbumin, transferrin, retinol
binding protein, insulin like growth factor-1
 Vitamin deficiencies
thiamine, vit A, D&E
 Mineral deficiencies
Zn, Mg, Cu, Ca
Nutritional Assessment of
patients with ESLD
Weight history?
Protein markers of nutritional status?
history of wasting?
Skinfolds?
Intake?
Appetite?
Nutritional Assessment of
patients with ESLD
 Anthropometry
 Food history
 Nausea
 Anorexia
 Taste changes
 Diarrhoea
 Early satiety
 Functional capacity
 Grip strength
Acute Hepatitis:
 High protein/high energy intake required to
promote hepatocyte regeneration
 Fat restriction contraindicated
 Nausea/anorexia
 Consider oral supplementation such as glucose
polymers, fruit based high protein drinks, or high

protein/ high energy drinks in the presence of
nausea/anorexia
 Caution against herbal remedies as some may be
harmful and most have no scientific basis
Malnutrition In Liver Disease
 Malnutrition is an early and typical aspect of hepatic
cirrhosis
 Contributes to poor prognosis and complications
 Degree of malnutrition related to severity of liver
dysfunction and disease etiology (higher in alcoholics)
 Mortality doubled in cirrhotic patients with malnutrition (35% vs
16%)
 Complications more frequent than in well-nourished (44% vs
24%)
 Usually more of a clinical problem than hepatic encephalopathy
itself
Stages of Hepatic
Encephalophay
Stage Symptoms
I Mild Confusion, agitation, irritability, sleep disturbance,
decreased attention
II Lethargy, disorientation, inappropriate behavior,
drowsiness
III Somnolent but arousable, slurred speech, confused,
aggressive
IV Coma
Nutritional Implications:
PCM associated Liver Dz
 Malnutrition reported in  Nutrient malabsorption/
65%-90% cirrhotic pts maldigestion
 Cholestatic & non-cholestatic
 Poor Dietary Intake
liver disease
 Anorexia  Excessive protein losses
 Dietary Restrictions  Pancreatic insufficiency
 Ascites
 Gastroparesis
 Abnormal Metabolism
 Hypermetabolism
 Zinc Deficiency
 Hyperglucogonemia
 Increased proinflammatory
cytokines  Increased protein metabolism
 Increased lipid oxidation
 Osteopenia
MNT in Advanced Liver Disease
 Poor Dietary Intake
 Due to poor appetite, early satiety with ascites
 Small frequent meals
 Aggressive oral supplementation
 Zinc supplementation
 Nutrient Malabsorption
 Due to bile, failure to convert to active forms
 ADEK supplementation
 Calcium + D supplementation
 Folic Acid Supplementation

MNT in Advanced Liver Disease
 Standard Guidelines
 MVI with minerals
 2gm Na restriction in presence of ascites
 Do not restrict fluid unless serum Na <120mmol
 Low threshold for NGT in pts awaiting transplant
 TPN should be considered only if
contraindication for enteral feeding
How Much Protein:
That is the Question
 Grade III to IV hepatic encephalopathy
 Usually no oral nutrition
 Upon improvement, individual protein tolerance can
be titrated by gradually increasing oral protein intake
every three to five days from a baseline of 40 g/day
 Oral protein not to exceed 70 g/day if pt has hx if
hepatic encephalopathy
 Below 70 g/day rarely necessary, minimum intake
should not be lower than 40 g/day to avoid negative
nitrogen balance

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Nutrition and liver

 Strategically placed such that all blood

 Metabolism of micronutrients – vitamins and

 Metabolism and excretion of drugs and

 Healthy diet according to healthy eating

 Beware of miracle cures

 Exhibit features of protein energy

 Consider oral supplementation such as glucose

polymers, fruit based high protein drinks, or high

 Folic Acid Supplementation

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