Kayla Monks, MS, RD, on Nutrition for Patients With Liver Disease

Kayla Monks discusses nutritional needs and challenges of patients with liver disease, including candidates for transplant, and how to work with patients to achieve the best possible outcomes.

Kayla Monks, MS, RD is a transplant dietitian and senior nutritionist at Beth Israel Deaconess Medical Center in Boston, Massachusetts.

TRANSCRIPT:

Hi there, my name is Kayla Monks. I am a registered transplant dietician at Beth Israel Deaconess Medical Center in the Transplant Institute. And I work closely with patients with liver disease undergoing transplant at Beth Israel.

I'm here today to discuss nutrition in cirrhosis throughout that journey. And I did have some assistance from my colleague, Lindsey Stone, a fellow transplant dietician, who helped me make some of the materials for today. Just briefly, we'll talk about nutrition in cirrhosis, the implications of liver and disease identification, assessment of malnutrition, as well as appropriate nutrition therapy and prescription of micronutrients and nutrition support when indicated.

So first off, nutrition in cirrhosis, why do we care? Malnutrition is widely recorded and highly variable with incidence rates up to greater than 90% of patients who have cirrhosis. The high variability is probably directly related to a lot of different reasons, but does vary or is directly associated with the stage of liver disease that patients are in and the level of their decompensation.

Malnutrition is underdiagnosed in these patients for a multitude of reasons, including knowledge gaps and inconsistent measurement tools, and there are also multiple challenges for diagnosing malnutrition in this population, including fluid retention in the form of ascites or edema; encephalopathy, which may make report a little more challenging to obtain; and increasing rates of obesity, making weight and physical exam more challenging and less reliable as well. But malnutrition is an independent predictor of mortality among our population and is associated with an increased prevalence of hepatorenal syndrome, ascites, increased hospital length of stay, and increased hospital costs. Additionally, patients with preoperative malnutrition and sarcopenia undergoing liver transplantation is associated with increased morbidity and mortality as well.

So malnutrition is multifactorial in this population, including inadequate dietary intake, which we'll talk about a little bit more in depth, but briefly due to nausea, ascites, loss of appetite, taste changes, alcohol intake, and then malabsorption due to portosystemic shunting, chronic pancreatitis, GI bleeding, bile acid deficiency, and then of course metabolic disturbances as well due to a hypermetabolic state and increased gluconeogenesis, so more rapid breakdown of muscle and fat, and then physical inactivity, increased sleeping, and sedentary lifestyle as well.

So, therefore, a routine and comprehensive nutrition assessment is very important in these in this patient population. Starting first with oral intake history to assess ongoing adequacy of oral intake and any barriers to their intake to best prescribe proper nutrition therapy going forward. Dentition should also be taken into account due to frequent dental caries and missing teeth as this can certainly impact oral intake. Anthropometrics, when assessing, we want to really be able to identify the patient's dry weight without their fluid on board and identify and try to assess to the best of our ability any weight changes and timeline of weight changes to assess true weight gains and true weight losses beyond simply fluid gains and losses going forward.

A physical exam is therefore really important as we can't just tell about a patient nutrition status from the scale alone; therefore, assessing really head to toe for muscle and fat losses, as well as their fluid status as well to have a better sense of what their weight is telling us. Functional status is also a component of nutrition assessment in our liver patients and hand grip strength and liver frailty index, which I won't go into in depth today, are validated tools for our population in assessment of their functional status.

And just aside note, of course I already mentioned, but encephalopathy and fluid status can be additional barriers in the assessment process as these can really make the overall assessment less reliable and more challenging to conduct.

So a little bit more about the barriers to inadequate intake as these are so significant in our population, but from early satiety due to abdominal distension, ascites, delayed gastric emptying, diet restrictions such as low sodium or low potassium if there are any hepatorenal concerns, low appetite, given ongoing inadequacy of intake and hormone dysregulation, encephalopathy if patients are home alone and having increased daytime sleeping or less support in the house to help stimulate that frequent intake.

Diarrhea, nausea, vomiting, obviously can lend themselves to decreased oral intake; altered taste in the setting of zinc deficiency, alcohol intake, and of course frequent admissions and procedures often requiring NPO or hypercaloric diets can really lead themselves to be ongoing barriers and the importance is assessing to the best that we can what barriers exist for each patient so that these can be targeted when coming up with the plan.

So for our goals for new therapy we want to optimize their nutrition status the best we can and minimize their risk for malnutrition so that they are able to improve their quality of life while living with liver disease and limit their risk for candidacy as a liver transplant patient if going that route and able to be a candidate otherwise; therefore, we want to increase their nutritional adequacy by providing a high-calorie, high-protein diet and avoiding long periods of fasting due to that hypercatabolic state. Ten-hour fast in patients with decompensated liver disease is equivalent to a 3-day fast in a healthy individual. So the reality is their muscle is breaking down at such a rapid rate. So therefore we emphasize small, frequent meals. and especially including a bedtime snack to avoid going those long periods without nutrition. We want to also work towards improving lean body mass and strength.

And like I said earlier, improving and managing those decompensation symptoms such as ascites and fluid retention by strict adherence to a low-sodium diet. For calorie needs, we want to assess patients using their estimated dry weight to the best of our ability. For well compensated patients, they need approximately 30 to 35 calories per kilogram of their estimated dry weight, or using an estimated dry weight derived or adjusted body weight from their estimated dry weight if their weight is greater than 120% of their ideal body weight.

For patients who have decompensated cirrhosis, we're elevating those needs to about 35 to 40 calories per kilogram and also closely monitoring their intake and estimating it with their needs and adjusting it as needed based on their trends and weight loss and physical exam. Patients with well compensated metabolic associated fatty liver disease believed to need about 25 to 30 calories per kilogram body weight or about a 500 to 800 calorie per day deficit to aid in some gradual healthy weight loss.

And patients who have decompensated metabolic-associated fatty liver disease, they're still lacking a general consensus, but may need greater calorie consumption for about 30 to 35 calories per kilo per day. But again, should be monitored closely to assure adequacy and minimize lean body mass prevention losses.

And therefore, protein is such an essential component of these patients’ intake. And the key is to not restrict protein. We want to minimize any lean body mass losses and we know a high protein diet can improve outcomes with patients with liver disease and maintain it helps us to maintain lean body mass. We recommend about 1.2 to 1.5 grams per kilogram body weight of protein. However, for patients who are using their adjusted weight to determine their needs, we do want to check that and make sure that patients are receiving at least 1 gram per kilogram of their actual body weight for protein.

Branched genome acid supplementation may be helpful per literature. However, lacking evidence-based outcomes at this time and costs and palatability are other barriers, so not frequently or routinely used in practice currently, but maybe some possibilities for that.

Other considerations to include are a fluid restriction if necessary for 1 or 2 liters based on a patient's fluid status, a sodium restriction of less than 2 grams sodium per day to help manage volume status. And it's important to note that 2 grams or sodium or 2,000 milligrams is less than 1 teaspoon of table salt, which is frequently significantly more than most patients are consuming. And patients often need significant help in label reading or health literacy to be able to include this restriction in an accurate way into their lifestyle. One simple strategy that I always employ is having patients look at the calories and sodium on a label and aiming for less sodium and milligrams per serving than calories because we know their need for calories supersedes their need for sodium per day.

Patients may also need potassium or phosphorus restrictions if any renal concerns; of course alcohol complete abstinence should always be reinforced by everyone on the team including the dietitian; and then again just helping them to practically incorporate all these restrictions and identify foods they can eat because this can feel highly restricted to a lot of our patients. Vitamins and minerals can be frequently deficient in our patients, so should be closely reviewed. Fat-soluble vitamins have increased risk of deficiency due to decreased and impaired storage and intake and synthesis. So vitamin D is frequently deficient and should be repleted or provided a daily maintenance dose if only mildly depleted. Vitamin A and vitamin E also have an increased concern for deficiency, especially in instances of cholangitis and should be checked and repleted. I do have the values for repletion on my content here, which I believe that we can link to at a minimum. And water-soluble vitamins have also increased risk of impaired absorption, especially in the intake of alcohol use. And if alcohol use or diuretics, thiamin with folic acid should likely be provided and I have that documented here as well.

For mineral concerns, first and foremost, zinc is highly frequently deficient due to increased losses with stooling and diuretics and decreased intake and if low should be repeated. However, we should always check a CRP with zinc to assure that we are taking into account inflammation as that can falsely deplete serum zinc levels. Selenium and copper also have increased risk of deficiency. Copper especially due to its concern with competing with zinc for absorption. So in cases of ongoing zinc repletion, copper should be routinely checked for. And then there is also concern for copper and manganese increased toxicity. So if given a multivitamin or multivitamin with minerals, we should just be checking for Tbili less than 5 for multivitamin with minerals. Otherwise, we should give without.

Nutrition support is often necessary in this patient population if unable to meet needs orally or in cases of severe and persistent malnutrition. Enteral nutrition is our first-line approach, ideally with an NG tube or an NJ tube for improved tolerance in patients with ascitesor ongoing nausea and gastrointestinal complaints. We would want to consider a concentrated formula or reduced fluid or a specialized formula if any renal concerns. And we might want to do continuous feeds of patients have ongoing very minimal oral intake or our NPO or on a hypochloric diet because we don't want to have any of those long gaps without nutrition. However, if patients are eating and are able to consume increasing amounts of oral nutrition, we would want to perhaps cycle their feeds overnight to help promote adequacy during the day orally and get even more nutrition needs met throughout the day as well.

And patients starting enteral nutrition do have a high risk of refeeding, so electrolyte should be closely monitored and typically, especially in cases of malnutrition, recommend enteral nutrition starting in hospital for that close monitoring.

Parenteral nutrition is really uncommon in last resort in this patient population due to risks of steatosis. However, may be necessary if only way to feed the patient. For considerations, we should pay attention to fluid concerns and keep volume as low as possible. And we also for conferred lipid want to keep that as low as possible ideally under 1 gram per kilogram as well.

So overall in summary, nutrition is a key component to evaluate in patients with liver disease. We want to help improve their nutrition status by providing a high calorie, high protein diet or nutrition support when indicated. We want to manage their decompensation symptoms by providing sodium or fluid restrictions and work to optimize their lean body mass and functional status with ongoing routine frailty testing and physical therapy as needed. And I believe that's it.

Thank you so much for listening.