Nutrition therapy: Integral part of liver transplant care

Table 1 Factors associated with malnutrition in patients on the waiting list for liver transplantation

Factors
Anorexia
Ascites
Altered taste perception
Metabolic and inflammatory derangements
Inadequate diet restrictions
Decreased social status
Polypharmacy
Multiple paracentesis
Variceal bleeding
Long fasting periods for labs and diagnostic procedures

Table 2 Subjective Global Assessment for patients on waiting list for transplantation[31] performance

Subjective Global Assessment

I. History

A. Weight

Height_______ Current weight______

Pre-illness weight _____

Weight in past 6 months: High_____ Low______

Overall change in past 6 months:_________

B. Appetite

Dietary intake change relative to normal

Appetite in past two weeks: ____good ____fair ____poor

Early satiety: _____none _____1-2 weeks _____ > 2 weeks

Taste changes: _____none _____1-2 weeks _____ > 2 weeks

C. Current intake per recall

Calories____ Protein______

Calories needs _____ Protein needs______

D. Persistent gastrointestinal symptoms

Nausea: _____none _____1-2 weeks _____ > 2 weeks

Vomiting: _____none _____1-2 weeks _____ > 2 weeks

Diarrhea (loose stools, > 3/day)

Number of stools per day_____/Consistency______

_____none _____1 weeks _____ > 1 weeks

Constipation: _____none _____1-2 weeks _____ > 2 weeks

Difficulty chewing: _____none _____1-2 weeks _____ > 2 weeks

Difficulty swallowing: _____none _____1-2 weeks _____ > 2 weeks

E. Functional capacity

_____ No dysfunction ____Dysfunction

_____ weeks

_____ working suboptimally

_____ ambulatory

_____ bedridden

II. Physical exam

A. Status of subcutaneous fat (triceps, chest)

_____ good stores _____ fair stores _____poor stores

B. Muscle wasting (quadriceps, deltoids, shoulders)

_____none _____mild to moderate _____ severe

C. Edema and ascites

_____none _____ mild to moderate _____ severe

III. Existing conditions

A.Encephalopathy

_____ none _____ stage I-II _____stage III _____ stage IV

B.Chronic or recurrent infection

_____ none _____ 1 week _____> 1 week

C.Kidney function

_____good/_____decreased (no dialysis)/_____decreased (with dialysis)

D.Varices

_____none/_____ varices (no bleeds)/_____ varices (with bleeds)

IV. Subjective Global Assessment Rating (based on sections I, II, III)

A._____ Well nourished

B._____ Moderately malnourished (or suspected of being malnourished)

C.______ Severely malnourished

Table 3 Nutritional recommendations in pre and peri liver transplant

Nutrients/Diet	Recommendations	Observations
Pre-transplant
Calories	35-40 kcal/kg	Avoid fasting for longer than 3-6 h during daytime; encouraged to take small, frequent meals distributed throughout the day
Protein	1.2-1.5 g/kg	It is suggested diets rich in vegetables and dairy protein
Carbohydrates	50%-70%	A late-evening snack of 50 g of complex carbohydrates is suggested to reverse aberrant substrate utilization and improve nitrogen retention
Fat	30%	It should not be restricted, unless true fat malabsorption has been diagnosed using a fecal fat test or slower gastric emptying is reported
Fiber	25-45 g/d	Prebiotics fermentation seems to have a beneficial effect on neuropsychiatric performance
Vitamin and minerais	Dietary Reference Intakes	Or pharmacological doses in case of deficiency
Peri-transplant
Calories	25-30 kcal/kg	Use indirect calorimetry if it is available
Proteins	1.5-2.0 g/kg	In the immediate phase after the operation, protein catabolism is markedly increased
Food/enteral nutrition		Early normal food or enteral nutrition (12 h) after liver transplant is advisable as long as the patient is hemodynamically stable and has no nausea or vomiting