Fasting state for cirrhosis patients

10-12 hrs

resting EE in cirrhosis

>30% and persist for 1 year post transplant

Vitamins deficiencies in liver disease

1. A rare
2. DEK
3. B12 rare long term
4. B6
5. B9 common

Thiamine deficiency causes

Wer-nicke's encephalopathy

Kossak-off psychosis

Dry weight for ascites and edema

1. Minimal 2.2 1
2. moderate 6. 5
3. Sever 14. 10

Golden standard assessment tool for per liver transplant

RFH SGA (4 domains )

measurement to predict 1 year mortality post-transplant and sarcopenia

Psoas Muscle Area (L3 PMA)

Nutritional requirements

Compensated 25-35 kcal/kg/d. 1.2-1.3 g

Decompensated 35-40 kcal/kg/d. 1.2-1.5 g

Post transplant 30% stress factor. 1.2-1.5g

No added salt diet content

recommended over low sodium diet

80-100 mmol/d

Glucose and AA requirement in alcoholic steatohepatitis and cirrhosis

IV 2-3 g/kg/day (fasting for >12 hrs)

50-60% of non-protein energy requirements

AA 1.2-1.5 g/kg/day

B1 prior to glucose infusion

ESPEN in Acute liver failure

IV 2-3 g/kg/day

Lipids 0.8-1.2 g/kg/day (if IR)

AA 0.8-1.2 g/kg/day

Is creatinine related to dietary protein intake

No, proportionate to muscle mass

marker for renal function, inadequate dialysis or muscle catabolism

Potassium goal, hyper, hypo levels, when to not restrict intake

goal 3.5-5.5 meq/l K+ number of lines = upper limit K=lower

hyper >6 meq/l

Urine >1000ml/day or serum normal level

CRF requirements

35 kcal/kg/day

Protein 0.55-0.6 g/kg/day

Po4 600-1000 mg/d

K+ 1500-2000 mgday

Na 1.8-2.5 g/day

Proposed solution to preserve renal function

Essential AA + ketoanalogues (low protein)

ESRF requirements

Protein intake (g/kg/day): 1.2–1.4 (50% HBV)

• Energy intake kcal/kg/day: 35

• Mineral Requirements:

– Phosphate (mg/day) 800–1000 or <17 mg/kg IBW (if GFR< 20-30 ml/min)

– Potassium (mg/g) 2000–2500 or 40mg/kg of IBW

– Sodium (g/day) 1.8–2.5

– Fluid (ml) 1000+urine volume

HD >5% weight gain reflect

reflect excessive fluid intake

HD Fluid gains of <2% reflect

Loss of body mass

Sodium and fluid balance based on urine output

- ≥ 1 L fluid output: 2-4 g Na and 2 L fluid

– ≤ 1 L fluid output: 2 g Na and 1-1.5 L fluid

– Anuria: 2 g Na and 1 L fluid

PD requirements

Energy: 35 kcals/kg/day

Sodium: (2-4 g/day)

Potassium: is easily cleared by PD

• Calcium: (<2000 mg elemental calcium)

– ~1500 mg: calcium-based phosphate binders

• Phosphorus: <800-1000 mg/day

– Use phosphate binders

• Fluid: can be adjusted by varying the dextrose

concentrations of the dialysate