Nutrition assessment in the presence of liver disease

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In early stages of liver disease, whether caused by alcohol, autoimmune processes, viral hepatitis, nonalcoholic fatty liver disease (NAFLD), metabolic disorders or other causes, typical objective nutrition

Table 4.1

Role of the Liver in Nutrient Metabolism

Protein metabolism

• Synthesizes serum proteins

• Synthesizes blood-clotting factors

• Forms urea from ammonia

• Deaminates/transaminates amino acids

• Forms creatine

• Oxidizes the amino acids arginine, histidine, lysine, methionine, alanine, tryptophan and tyrosine

Carbohydrate metabolism

• Glycogenesis

• Gluconeogenesis

• Glycogenolysis

Fat metabolism

• Hydrolyzes triglycerides, cholesterol and phospholipids to fatty acids and glycerol

• Synthesizes cholesterol

• Performs ketogenesis

• Forms lipoproteins

• Produces bile necessary for fat absorption Vitamin metabolism

• Site of enzymatic steps in vitamin activation o Thiamine (thiamine pyrophosphate) o Pyridoxine (pyridoxal phosphate) o Folic acid (tetrahydrofolic acid) o Vitamin D (25-hydroxycholecalciferol)

• Synthesizes carrier proteins for vitamins such as A and B12

• Synthesizes lipoproteins to transports vitamin E

Mineral metabolism

• Stores copper, iron and zinc

Reprinted from Hasse JM. Nutritional aspects of adult liver transplantation. In: Busuttil RW, Klintmalm GB, eds. Transplantation of the liver, 2nd edn. Philadelphia: W.B. Saunders. 2005, with permission from Elsevier.

Oriantation The Body Diagram

EXTERNAL SYMPTOMS INTERNAL SVMPTOMS

Fig. 4.1. Clinical manifestations of cirrhosis. Reprinted from Hasse JM, Matarese LE.Medicalnutrition therapyfor liverbiliary system, andexocrinepancreasdisorders. In: Mahan LK, Escott-Stump S (eds) Krause's food, nutrition, and diet therapy, 11thedn.Philadelphia:W.B.Saunders.2004,with permission from Elsevier.

EXTERNAL SYMPTOMS INTERNAL SVMPTOMS

Fig. 4.1. Clinical manifestations of cirrhosis. Reprinted from Hasse JM, Matarese LE.Medicalnutrition therapyfor liverbiliary system, andexocrinepancreasdisorders. In: Mahan LK, Escott-Stump S (eds) Krause's food, nutrition, and diet therapy, 11thedn.Philadelphia:W.B.Saunders.2004,with permission from Elsevier.

Fig. 4.2. Severe malnutrition and ascites in a man with end-stage liver disease. Reprinted from Hasse JM, Matarese LE. Medical nutrition therapy for liver biliary system, and exocrine pancreas disorders. In: Mahan LK, Escott-Stump S (eds) Krause's food, nutrition, and diet therapy, 11th edn. Philadelphia: W.B. Saunders. 2004, with permission from Elsevier.

Fig. 4.2. Severe malnutrition and ascites in a man with end-stage liver disease. Reprinted from Hasse JM, Matarese LE. Medical nutrition therapy for liver biliary system, and exocrine pancreas disorders. In: Mahan LK, Escott-Stump S (eds) Krause's food, nutrition, and diet therapy, 11th edn. Philadelphia: W.B. Saunders. 2004, with permission from Elsevier.

assessment parameters can be used to determine nutrition status. However, when signs of end-stage liver disease (ESLD) develop (Figs. 4.1 and 4.2), objective parameters are not always valid. See Table 4.2 for a summary of the benefits and drawbacks of specific assessment techniques in the presence of liver disease.

Table 4.2

Benefits and Drawbacks of Nutritional Assessment Parameters when Assessing Individuals with End-Stage Liver Disease

Parameter

Benefits

Drawbacks

Body weight

Anthropometric measurements (triceps skinfold, arm muscle circumference)

Hand-grip strength

Serum protein values

• Simple to perform

• Reproducible

• Universal measurement

Urinary tests

(e.g., nitrogen balance, creatinine-height index)

Immunocompetence tests [e.g., skin test antigens, total lymphocyte count (TLC)]

• Reproducible

• Easily available

• Relatively low cost

Relatively low cost

• Reproducible

• Relatively low cost

• TLC easily available

Affected by body fluid changes

Low interrater reliability Influenced by a patient's fluid status Low specificity and sensitivity

Low specificity and sensitivity Influenced by patient's mood and neurologic status

Affected by many non-nutritional factors (e.g., fluid status, liver function, vitamin status)

Influenced by many non-nutritional factors (e.g., renal and liver function, fluid status)

Influenced by immunosuppressive states and drugs

(Continued)

Parameter

Other tests such as bioelectrical impedance (BIA), dual energy X-ray absorptiometry (DXA)

Table 4.2 (Continued)

Benefits

• DXA considered highly accurate

Drawbacks

• BIA affected by fluid status; BIA equation must be valid for population being evaluated

• Increased cost

• Unavailability or lack of daily clinical application

Adapted from: Hasse JM, Matarese LE. Solid organ transplantation. In: Gottschlich MM (Ed) The A.S.P.E.N. Nutrition Supportcore curriculum: A case-based Approach-The adult Patient. Silver Spring, MD: The American Society for Parenteral and Enteral Nutrition. 2007:599-618, with permission from the American Society for Parenteral and Enteral Nutritio (A.S.P.E.N). A.S.P.E.N does not endorse the use of this material in any from other than its entinety.

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