5/31/2018

End Stage Liver Disease
NUTN515 Case Study

DATE:  MAY 31, 2018   PRESENTED BY: JACQUELINE CHEN,  M.S.; DIETETIC  INTERN

Outline 
• Patient L.S.
• Background
– End Stage Liver Disease (ESLD)
– Associated complications
– Liver transplants
• Nutrition Assessment
– Nutrition Focused Physical Exam
(NFPE)
• Nutrition Diagnosis
• Nutrition Interventions and Goals
• Outcomes
• Discussion

Patient: L.S.
• 46 YOF
• Admitting Dx: abdominal pain, distended
abdomen, and spontaneous bacterial
peritonitis (SBP) with evidence of E. coli
bacteremia
• PMH:
– ESLD
– Cryptogenic cirrhosis
– Esophageal varices without bleeding s/p
ligation
– Ascites requiring weekly large volume
paracentesis
– Worsening renal function
Cholecystectomy in 1996

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End Stage Liver Disease
• Progressive disease
• Fatty liver:
– Non-alcoholic
fatty liver disease
(NAFLD)
– Non-alcoholic
steatohepatitis NIDDK NIH, 2014
(NASH)
• Fibrosis
• Cryptogenic cirrhosis

Associated complications of 
ESLD
• Portal hypertension
• Esophageal varices
• Edema and ascites
– SBP
• Declining renal function
• Malnutrition

Photo: transplant.surgery.ucsf.edu

Diagnosis of Liver Disease 
Severity
• Physical exam
• Endoscopy
• Lab tests
• Imaging
• MELD score for liver transplant

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17% of patients on the active 
liver transplant list die annually.

Current survival rate for 
transplant after 5 years is 75%.

Nutrition Assessment: 
Anthropometrics
• Height: 157.48 cm (62 inches)
• Weight: 79.2 kg
– BMI: 31.9, inaccurate d/t fluid status
– Standing wt, ascites + LE swelling
• UBW: 73.2 kg
– BMI 29.5
– Pt report of dry wt

• Weight history:
– 20# wt loss in past 4 years (82.6 kg in
2013)

Weight change in kg (Jan 29‐ March 3) 
81

79

77

75
Pt reported dry wt: 73.2 kg
Wt in kg

73

71

69

67

65
29‐Jan 2‐Feb 6‐Feb 10‐Feb 14‐Feb 18‐Feb 22‐Feb 26‐Feb

Date

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Nutrition Assessment: 
Biochemical Data
• E. coli + (1/29) and Candida + (1/31)
– No signs of bacterial or yeast infections
2/7
• CBC (January and February 2018)
– WBC <3.5 (low) in Jan , >3.5 (normal) in
Feb
– RBC <2 (low)
– Hg <7 (low)
– Hct <20 (low)
– MCV >105 (high)
– 8/20/17 MMA 0.12 (nl), B12 >6000 (high)
– Ferritin 1157 (2/7, high)

Nutrition Assessment: 
Biochemical Data
• Complete metabolic panel (Jan and Feb
2018)
– Na <129, hyponatremic
– K >5 (trending high) in Jan, <5 (nl) in Feb
– Bilirubin total: always high
• Trend up: 3.2 (1/29), 5.2 (1/30), 8.5
(1/31), 11.6 (2/3), 16.4 (2/5)
• Trend down: 15.4 (2/6), 12.1 (2/7), 9.2
(2/16)

Nutrition Assessment: Biochemical 
Data
Liver related labs Renal function set
• Negative for esophageal (2/7/18)
bleeding EGD (7/2013) • GFR 25 (Stage 4 CKD)
• AST, ALT, and Alk Phos WNL – 1/29: Cr 1.37, GFR 46 (Stage
• INR >2.46 (high, trending up) 3A CKD)

• Zinc serum 37 (2/7, low) • Potassium 3.6 normal

• Ceruloplasmin 12 (2/7, low) • Phosphorus 5.8 (high),

decreased to 3 (2/13)
• MELD score
• Calcium corrected <8.6 (low),
>8.6 (2/18/18)

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MELD scores during hospitalization
50
45
40
35
30
25
20
15
10
5
0
6‐Mar
Jan 256‐Mar
Jan6‐Mar
30 6‐Mar
Feb 4 6‐Mar
Feb 9 6‐Mar
Feb 6‐Mar
14 6‐Mar
Feb 19 6‐Mar
Feb
24 Mar 1 Mar 6

Medications
• Pre- admit medications
– Daily Cipro prophylaxis (500 mg) for SBP
– Ascorbic acid 500 mg/d
– Cholecalciferol (D3) 1000 IU/d
– Ferrous sulfate 325 mg/d
– Furosemide 40 mg/d
– Lactulose 30 ml/d
– Levothyroxine 25 mcg/d
– KCl 1 tablet/d
– Prenatal vitamin w/ calcium, iron, folic acid
– Rifaximin 550 mg /d
– Spironolactone 100 mg/d

Medications
• Meds related to SBP and infection
– IV ceftriaxone 2g q12 hr
– IV cefepime 2g q12 hr
– Flagyl 500 mg oral
– Culturelle 1 capsule daily
• Medications related to hepatic
encephalopathy
– Lactulose 20 g TID oral
– Rifaximin 550 mg BID oral
• Other medications
– Levothyroxine 25 mcg oral/d
– IV albumin: 1-1.5 g/kg
– Zinc sulfate 50 mg elemental
• Diuretics on hold

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Drug‐Nutrient Interactions
• Antibiotics
– N/V/D, altered taste and appetite, yeast infections, anemia
• Liver medications
– Gas, bloating, stomach pain, nausea, cramping,
dehydration
• Levothyroxine
– Hold TF for 1/2 hour before and after
• Zinc sulfate
– Nausea, stomach upset,
heartburn

Nutrition Focused Physical Exam
• Initial 1/31 (2 days
post admit)
• Post-5L LVP 2/6
• Reassessment 2/21

Photo: Cancer Research UK / Wikimedia Commons

Diet History & Nutrient Needs
• Usual intake: 2 meals/day
• Spanish style home-cooking
• Poor intake d/t pain
• Tired of hospital menu

Nutrient Needs:
• 1/31 (73.2 kg): 2200-2500 kcals (30-35 kcal/kg), 73-110 gm
protein (1-1.5 gm/kg)
• 2/16 (73.2 kg): 2200-2500 kcals (30-35 kcal/kg), 88-110 gm
protein (1.2-1.5 gm/kg)

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Diagnosis
1. Inadequate oral intake related to poor
appetite as evidenced by 20# wt loss from
reported UBW over time and 10-50% intake
of last few meals per pt report and flowsheet.

2. Malnutrition related to inadequate po intake

as evidenced by pt meeting the following
criteria suggesting: Severe protein-energy
malnutrition
– Depletion of fat stores: moderate
– Depletion of muscle mass: severe 


Treatment Goals
• Goals for treatment of liver
disease:
– Slow progression of
cirrhosis
– Treat complications of
disease (edema, ascites,
infections)
– Improve malnutrition
status
– Eventual goal: liver
transplant if necessary

MNT for Liver Disease
• Increased risk for malnutrition
• Enteral nutrition and ONS
• SFM, include HS snack
• Calories: 35 to 40 kcal/kg
• Protein: 1.2 to 1.5 g/kg
• Restrict fluid, sodium, and fat
• Vitamin D supplementation
• Watch K, Ca, Phos

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Nutrition Interventions
• SFM (3 meals + 3 snacks)
• Family encouragement
• Increase protein
• Decrease sodium
• Culturelle probiotics
• Oral nutritional supplements
– Boost Pudding
– Ensure Compact
– Beneprotein

Significant Event: Transfer to 
ICU
• 2/6: Fall resulting in subdural
hematoma
• 2/9: Initiate Nepro TF
– Goal: 45 mL/hr x 23 hr
– 1863 kcal, 84 g protein, ~755 mL
usable fluid
• 2/16: TF discontinued
• 2/17: DHT removed

Short‐term Outcomes
• Infection resolved by 2/7 (negative test)
• Weekly LVP
• Depressed mood
• Poor po intake continued
• Consult for discharge TF recommendations
• Pt remained malnourished until discharge on
3/3
– Improvement in muscle mass depletion

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Liver transplant?

Liver Transplant
• 2/5: MELD 40 score for transplant
• 4/17: Liver transplant
• 4/25: Discharged from OHSU
– Severe protein-energy malnutrition:
• Rate of weight loss: <7.5% in 3 mo
• Energy intake: <50% intake compared to
energy requirement for > 7 days
• Depletion of fat stores: moderate (orbital
and buccal fat pads)
• Depletion of muscle
mass: moderate/severe (temporalis,
pectoralis, trapezius)

Post‐transplant 
outcomes

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Discussion
• Obtain labs:
– Vitamin D 25 hydroxy
– MMA and homocysteine
– Vitamin A
• Start MVI w/ fat soluble
vitamins
• Referral to psychologist
• Earlier family involvement
• Initiate TF sooner
• Consider TPN?

References
1. UCSF Transplant Surgery. Transplant Surgery - End-stage Liver Disease (ESLD). 2018.
https://transplant.surgery.ucsf.edu/conditions--procedures/end-stage-liver-disease-(esld).aspx.
Accessed April 28, 2018.
2. Perri G-A, Ccfp M, Khosravani H, Frcpc P. Complications of end-stage liver disease. Can Fam
Physician. 2016;62:44-50.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721840/pdf/0620044.pdf. Accessed April 29,
2018.
3. Dever JB, Sheikh MY. Review article: spontaneous bacterial peritonitis - bacteriology, diagnosis,
treatment, risk factors and prevention. Aliment Pharmacol Ther. 2015;41(11):1116-1131.
doi:10.1111/apt.13172.
4. Cheng XS, Tan JC, Kim WR. Management of renal failure in end-stage liver disease: A critical
appraisal. Liver Transplant. 2016;22(12):1710-1719. doi:10.1002/lt.24609.
5. American Liver Foundation. Liver Transplant. 2017. https://www.liverfoundation.org/for-
patients/about-the-liver/the-progression-of-liver-disease/liver-transplant/#information-for-the-
newly-diagnosed. Accessed April 28, 2018.
6. Lalama MA, Saloum Y. Nutrition, fluid, and electrolytes in chronic liver disease. Clin Liver Dis.
2016;7(1):18-20. doi:10.1002/cld.526.
7. Ferreira LG, Ferreira Martins AI, Cunha CE, Anastácio LR, Lima AS, Correia MITD. Negative
energy balance secondary to inadequate dietary intake of patients on the waiting list for liver
transplantation. Nutrition. 2013;29(10):1252-1258. doi:10.1016/j.nut.2013.04.008.
8. Amodio P, Bemeur C, Butterworth R, et al. The nutritional management of hepatic
encephalopathy in patients with cirrhosis: International society for hepatic encephalopathy and
nitrogen metabolism consensus. Hepatology. 2013;58(1):325-336. doi:10.1002/hep.26370.
9. Paternostro R, Wagner D, Reiberger T, et al. Low 25-OH-vitamin D levels reflect hepatic
dysfunction and are associated with mortality in patients with liver cirrhosis. Wien Klin
Wochenschr. 2017;129(1-2):8-15. doi:10.1007/s00508-016-1127-1.

Thank You

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