Beruflich Dokumente
Kultur Dokumente
POLICY/PROCEDURE TITLE:
Nutrition protocol
DISTRIBUTE TO:
All supporting staff for the liver
program radiology, pathology
[ X] ADMINISTRATIVE [X ] CLINICAL
PAGE 1 OF 6
RELATED TO:
Effective Date:
Updated: NA
Revision Date: NA
[ x ] Patient Care
[ ] JCAHO
[x ] Nursing Practice
[ ] UNOS
Other Approval: NA
Policy/Procedure
Completed
Committee Approval:
I. Obesity
Introduction
Obesity is a major medical problem, defined by a body mass index (BMI) of 30 kg/m 2 or
greater. Obesity may result in technical challenges to liver transplant surgery, increase
risk for wound dehiscence (1), increase infectious complications (2, 3), result in a longer
hospital stay (4), increased cost (5) and decreased survival following liver transplant (3,
5). The rate of primary liver graft nonfunction is also increased in patients with BMI >35
kg/m2 (5). Obesity is a recognized risk factor for multiple medical problems that may
significantly impact survival and quality of life in the liver transplant population. These
include diabetes, hyperlipidemia, cardiovascular disease, and cancer. Pre-transplant
obesity is an independent risk factor for development of metabolic syndrome following
liver transplant (6).
Classes of over weight and obesity defined by the World Health Organization:
BMI 25-30 kg/m2
overweight
BMI 30-35 kg/m2
obese
BMI 35-40 kg/m2
severely obese (morbid)
BMI >40 kg/m2
very severely obese (super morbid)
AASLD practice guidelines published in 2005 state that morbid obesity (defined in this
paper as BMI >40 kg/m2) should be considered a contraindication to liver transplant (7).
4. A goal weight will be established to achieve a BMI <35 kg/m2, and target a
healthy BMi in the 24-26 range (using a dry weight) will be advised for all patients
and each patients will be asked to sign a weight loss contract. The patient will be
asked to lose at least 20% of their excess weight within 6 months of signing
A weight contract will be signed by the patient at the time of their dietary
consultation
i.
This contract can consider <1200 calories per day due after an
assessment of risk of malnutrition is completed.
ii.
At least 1.2-1.5 gm/kg of protein intake per day is
recommended in the absence of concomitant renal disease.
i.
The contract will include expectations regarding exercise (see
below)
When the patient meets the established goal weight, the patient will be
activated for liver transplant.
If the patient is not able to meet weight loss goals, the patient will not be
considered a candidate for liver transplant. The patient will be informed
of their failure to meet their weight loss target (in person and in writing),
and will be removed from the liver transplant list after one year of
attempted weight loss.
5. In addition to meeting with the liver transplant dietician, a weight loss group, such
as Weight Watchers, Jenny Craig, Nutrisystem, or other acceptable weight loss
plan, may be recommended to patients in selected cases.
6. The patient will be required to exercise and have a fitness plan tailored to their
medical condition. Recommendations should be 30 minutes of exercise at least
5 days per week.
If the patient has physical limitations that preclude exercise, then
referral to physical therapy will be strongly recommended.
7. Patients may be referred for bariatric surgery (vertical banded gastroplasty) if:
The major goals of pre-transplantation nutritional therapy are to first correct any macroand micro-nutrient deficiency and later to prevent further nutrient and protein depletion.
Nutrition support therapy should be inclusive of energy requirement (calories), protein
100 gms per day, vitamins, minerals, and trace elements. Patients with liver cirrhosis
exhibit early onset of gluconeogenesis after short-term fasting. Patients with portal
hypertension have documented fat malabsorption made worse by cholestasis. This
accelerated metabolic reaction to starvation may underlie their increased protein
requirements and muscle depletion. Provision of a nighttime feed (supplemental
nocturnal tube feeds) to patients with cirrhosis results in body protein accretion
equivalent to about 2 kg of lean tissue sustained over 12 months when compared to
patients supplemental during daytime hours (24). Energy and protein intake increased
similarly in both treatment groups thus it is hypothesized that by limiting the overnight
fasting period with a late-evening meal the progression to early onset of nocturnal
gluconeogenesis from amino acids is blunted with improvement in net nitrogen balance.
Perioperative
nutritional support with 14 days of parenteral nutrition in addition to oral diet has been
reported to reduce complications after major hepatectomy for hepatocellular carcinoma
associated with cirrhosis compared to patients receiving oral diet alone (25).
2. Vitamin A Deficiency
Most patients with chronic liver disease obtain adequate vitamin A from a
multivitamin (RDA for adult males in 3000 IU and for adult females in 2300 IU).
Patients with cholestasis and deficiency may require 5,000-25,000 daily IU. Patients
on high dose supplements require monitoring for toxicity. Blood levels should be
checked every 6 months while on high dose therapy.
3. Vitamin E Deficiency:
Vitamin E deficiency is rare and may be manifest as neuromuscular disorders or
hemolysis.
Serum measurements of vitamin E are unreliable and so accurate levels require
concomitant measurement of fasting lipids. In individuals with fat malabsorption, 200
IU daily is usually sufficient to replace vitamin E in healthy people. Up to 800 units
per day may be used in CLD patients.
4. Vitamin K Deficiency:
Dietary vitamin K1 (phyloquinones) is found in green leafy vegetables (spinach, kale,
broccoli) while normal gut flora may synthesize vitamin K2 (menaquinone). Vitamin K
has a major role in the coagulation pathway and is also a cofactor for bone
mineralization. Risk factors for deficiency include poor dietary intake, cholestasis
with malabsorption, and chronic antibiotic use. Daily requirements are 90mcg for
women and 120mcg for men. Oral Vit K appears to have little or no effect on INR
levels due to lack of absorption combined with low efficiency of Vit K
activation.
If increased INR, attempt repletion with Vitamin K 10 mg SQ daily, for three days.
Parenteral vitamin K may be given monthly for maintenance, if required. This would
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be most commonly done in patients with primary cholestatic liver disease (PBC or
PSC).
Vitamin K
Vitamin A
Vitamin E
Vitamin D
ADEK
150 mcg
5000 IU
50 IU
400 IU
11
References
1.
Schaeffer DF, Yoshida EM, Buczkowski AK, et al. Surgical morbidity in severely
obese liver transplant recipients - a single Canadian Centre Experience. Ann Hepatol
2009;8:38-40.
2.
Sawyer RG, Pelletier SJ, Pruett TL. Increased early morbidity and mortality with
acceptable long-term function in severely obese patients undergoing liver transplantation.
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3.
Dick AA, Spitzer AL, Seifert CF, et al. Liver transplantation at the extremes of
the body mass index. Liver Transpl 2009;15:968-77.
4.
Nair S, Cohen DB, Cohen MP, et al. Postoperative morbidity, mortality, costs,
and long-term survival in severely obese patients undergoing orthotopic liver
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5.
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6.
Ruiz-Rebollo ML, Sanchez-Antolin G, Garcia-Pajares F, et al. Risk of
development of the metabolic syndrome after orthotopic liver transplantation. Transplant
Proc;42:663-5.
7.
Murray KF, Carithers RL, Jr. AASLD practice guidelines: Evaluation of the
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8.
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9.
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11.
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12.
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before liver transplantation: a prospective cohort study of nutritional and metabolic
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13.
Figueiredo F, Dickson ER, Pasha T, et al. Impact of nutritional status on
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16.
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17.
Detsky AS, Baker JP, Mendelson RA, et al. Evaluating the accuracy of nutritional
assessment techniques applied to hospitalized patients: methodology and comparisons.
JPEN J Parenter Enteral Nutr 1984;8:153-9.
18.
Hasse J, Strong S, Gorman MA, et al. Subjective global assessment: alternative
nutrition-assessment technique for liver-transplant candidates. Nutrition 1993;9:339-43.
19.
Figueiredo FA, Dickson ER, Pasha TM, et al. Utility of standard nutritional
parameters in detecting body cell mass depletion in patients with end-stage liver disease.
Liver Transpl 2000;6:575-81.
20.
Alvares-da-Silva MR, Reverbel da Silveira T. Comparison between handgrip
strength, subjective global assessment, and prognostic nutritional index in assessing
malnutrition and predicting clinical outcome in cirrhotic outpatients. Nutrition
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22.
Englesbe MJ, Patel SP, He K, et al. Sarcopenia and mortality after liver
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23.
Afilalo J, Eisenberg MJ, Morin JF, et al. Gait speed as an incremental predictor of
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Plank LD, Gane EJ, Peng S, et al. Nocturnal nutritional supplementation improves
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Kennel KA, Drake MT, Hurley DL. Vitamin D deficiency in adults: when to test
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Arteh J, Narra S, Nair S. Prevalence of vitamin D deficiency in chronic liver
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Figure 1 demonstrating inferior survival following liver transplant in patients with BMI <
18.5 or 40 compared to those with pre-transplant BMI between 18.5 and < 40 (3).
Compared with the control group, the underweight patients had a higher
retransplantation rate due to graft failure and were more likely to die from hemorrhagic
complications or cerebrovascular accidents.
Analysis of Variables as Predictors of Risk to Survival During Period 3 (March 2002 to
2007; n=27,709 Patients). Shown are results of multivariable analysis
Variable
RR
Rank Order
Cryptogenic Cirrhosis
Retransplant
Tumor
BMI < 18.5
Hepatitis C
On life support at time of transplant
BMI 40
DCD Donor
3.71
1.76
1.74
1.73
1.52
1.44
1.41
1.36
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.0005
<0.0001
1
2
3
4
5
6
7
8
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