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Liver disease Cheat Sheet (DRAFT) by

Liver disease MNT Dietetics

This is a draft cheat sheet. It is a work in progress and is not finished yet.

What is it?

any condition that damages the liver and affects its ability to function
Progre­ssion: Healthy liver → Fatty Liver → Inflam­mation (hepat­itis) → fibrosis of liver → cirrhosis liver (irrev­ers­ible)
AKA: Healthy liver → NAFLD → NASH → cirrhosis

Causes

Hep A & C
autoimmune disease
liver cancer
toxins (alcohol, smoking)
metabolic conditions
obesity
DM
hyperi­nsu­linemia

Biochem

Marker
Expected in LD
Explan­ation
LFT (ALP, GGT & bilirubin)
↑
Bile flow is blocked (biliary obstru­ction, intrah­epatic extrah­epa­tic). They can also rise with liver tumours or obesity
AST & ALT
↑
↑ ALT only = mild hepatic damage. ↑ ALT and AST = hepatic damage. Markers of recent (hours­/days) liver injury (though AST can also rise with muscle damage. Damage to liver cells = release of AST and ALT (found in hepato­cytes).
CRP
↑
Marker of inflam­mation
Albumin & prealbumin
↓
Indicate cirrhosis and end stage liver disease. Albumin is synthe­sised in the liver. Poor indicator of nutrit­ional status in liver disease patients. Correlate with the progre­ssion and severity of LD.
Vit A, D, E, K
↓
Fat malabs­orption (↓ bile)
Zinc
↓
Develops from low intake, poor absorption (↓ bile, ↓ albumin), and diuretic (treat ascites) loss; linked to taste changes, glucose issues, enceph­alo­pathy, poor healing, and weakened immunity.
Thiamine
↓
Stores & activates @ liver. ↓ hepatic reserves and alcohol intake preventing the conversion into its active form.
B12
↓ (tissue), ↑ (serum)
Reduced hepatic stores. Liver cells release stored B12 when damages.
Folic Acid
↓
Liver stores & metabo­lises folate into its active form. Reduced hepatic reserves
Calcium
↓
Vitamin D defici­encies
Selenium
↓
↓ absorption and intake
 

Functions of the liver

P, CHO, F metabolism
Drug metabolism
Stores: fat sol-vits, zinc, iron, copper and magnesium
Secretes bile – fat absorption
Synthesis: albumin, prealb­umin, retino­l-b­inding protein & clotting factors
Stores glycogen
+ many more!

Stages

Child Pugh Score

5-6 points
Grade A = 85-100% survival rate. Well compen­sated.
7-9 points
Grade B = Signif­icant functional compro­mise. 60-80% survival
10-15 points
Grade C = decomp­ensated disease. 35-45% survival rate

NIS

Liver stores glycogen = unable to regulate blood sugar. Needing small regular meals
Maldig­estion & malabs­orp­tion: reduced bile (fat malabs­orp­tion), pancreatic insuff­iciency
Altered taste, nausea
Portal hypert­ension: in advanced liver disease. Vessels in liver blocked (eg scaring) = Blood merges into portal vein in liver = ↑ pressure = backflow of blood
 
Oesoph­ageal varices - dilated Abnormal veins – may bleed = reduced oral intake, dysphagia, text-mod
 
Ascites - Abdominal swelling caused by accumu­lation of fluid. Malnut­rition ↑s risk. Can’t use a PEG. early satiety, fluid & NA restri­ctions
 
Enceph­alo­pathy (HE)– alters brain function. Confusion, memory, shaky, trouble talk/walk. inability to self-feed, dysphagia, tiredness, malaise (general feeling unwell). Stage 0 (no abnorm­ali­ties)-4 (coma)
Jaundice: liver cirrhosis or liver cancer. Serum bilirubin >2.5-3 mg/dL. Loss of liver function to metabolise bilirubin (damaged hepato­cytes) = bilirubin builds up

Nut Reqs

USE DRY WEIGHT
Compen­sated liver disease: 100-14­5kJ­/kg/day (CQHHS)
NASH, cirrhosis, transp­lan­tation, hepatic enceph­alo­pathy: 145 – 165 kJ/kg/day (CQHHS), ESPN = 30-35k­cal/kg
Protein: 1.2 -1.5 g/P/kg/d (CQHHS). 1.5 for cirrhosis
Fat: Restrict if: signs of fat malabs­orp­tion. Don’t remove as it’s a source of fat-sol V & concen­trated energy
Na: 2g/day (CQHHS)
Risk of deficiency (alcoholic liver disease): folate, Vit C, B group
Prevent toxicity: Copper & magnesium
Thiamine: 100mg OD-TDS
Vitamin D: 400-80­0IU/day
Vitamin K: 10mg every 4 weeks K: 10mg every 4 weeks
Calcium: 1200-1­500­mg/day
Zinc: multiv­itamin can be used
 

Interv­ention

NAFLD: Weight loss – similar to T2DM – intensive lifestyle.
↓ weight, lifestyle behavi­ours, euglyc­emi­a/n­ormal lipids­/normal BP = reduce portal hypert­ension
CLD (NASH, Cirrho­sis): HPHE. Malnut­rition strate­gies. Maintain muscle mass.
 
Screen malnut­rition (RFH-NPT) and Sarcopenia (SARC-F) - Prevent sarcop­enia, severe fatty liver, infect­ions, LOS, mortality, HE
 
Varices: softer foods without sharp edges to avoid bleeds
 
Ascites – Na 60 mmol/day (ESPEN)
 
EN (NGT) – intake is <70-80% of reqs (CQHHS) eg oesoph­ageal varies. 1.5-2 kcal feed.
 
PN – liver failure - 2-in-1 bag (no fat)
 
Thiamine supple­men­tation before PN to prevent Wernic­ke-­Kor­sakoff syndrome
 
Minimise fasting
 
BCAA Supps (12-14­g/day delivered in the evening before sleep)
For alcoholic liver disease (not w/ cirrho­sis): initial remove alcohol & treatment withdrawal S/S. Correct defici­encies.
V&M affected by alcohol: ↓ folic acid, thiamine, B6, niacin, Vit K, Vit C, Vit D, Vit A, iron, K, Mg
Refer
EP. Speechie
Consider
DO THEY HAVE ASCITIES? Swallowing function, ability to self-feed, textur­e-mod, refeeding risk

Strategies

Malnut­rition strategies - ONS, EN/PN
6-8 meals/day. Max. 6-7 hours without any intake (CQHHS)

Monitoring

tolerance to feeds
wt
N/V/D
nut defici­encies
re-asses reqs
restri­ction changes

Example PESS

NAFLD: Excessive oral intake, Food and nutrition knowledge deficit
NASH/S­evere CLD: malnut­rition, Inadequate protei­n-e­nergy intake, Inadequate oral intake

Guidelines & References

ESPEN guideline on clinical nutrition in liver disease (2019)
ESPEN practical guideline: clinical nutrition in liver disease (2020)
FEEDS Gastro­ent­erology and liver disease
Central Queensland Nutrition guidelines for liver disease management 2019