NUTRITION AND

LIVER DISEASE

Diah Krisnansari
Outcome
 Describe recommended nutrition therapies for
individuals with liver disease:
 - Nutrient Needs
 - Other Supplements
References
 1. Mark H. DeLegge, 2008. Nutrition and Gastrointestinal
Disease
 2. Judith Fitzhugh , 2008. Nutrition& Liver Disease, Minimizing
Symptoms and Optimizing Health
3. Anne S Henkel and Alan L Buchman. 2008. Nutritional
support in patients with chronic liver disease
 4. Elsevier Inc, 2004. Medical Nutrition Therapy for Liver,
Biliary System, and Exocrine Pancreas Disorders
Introduction

3-1/2 pounds (weighing 1-1.5kg in adults)

One of the largest organs
8”wide x 6.5”height x 4.5”deep
Nutrition Related Functions

 Manufacturing Plant
 Storage Facility
 Waste Disposal
Liver & Related Organs
Manufacturing Functions

 Protein- for the bloodstream (albumin)

 Glycogen- storage form of glucose for energy
 Bile- to help digest fats that are needed for
cell structure and energy
 Cholesterol – and special proteins to carry fat
through the blood
Storage Facility

 Glycogen-released when our bodies need

energy (this includes during sleep for basic
metabolism)
 Iron- most is stored in the liver
Waste Disposal

 Ammonia - from the breakdown of dietary

protein and muscle tissue
 Bilirubin - from the breakdown of red blood
cells
 Bacteria – removed from the bloodstream
 Drugs and Alcohol - are metabolized in the
liver
Normal Liver vs. Damaged Liver
Microscopic Appearance of (A) a Normal Liver
and (B) Acute Fatty Liver
Clinical Manifestations of Cirrhosis
Severe Malnutrition and Ascites in a Man with
End-Stage Renal Disease
Clinical manifestations of cirrhosis
Liver Disease
 Liver disease is prevalent, affecting 5.5 million
Americans; it is the 12th leading cause of death in the
US .
A majority (60–70%) of adults in industrialized countries
drink alcohol which is one of the leading causes of liver
disease

• Signs: - muscle wasting

- decreased fat stores,
- poor appetite, satiety (leptin)

 Malnutrition
Malnutrition in Liver Disease—Cause
Liver disease

• Malnutrition is highly prevalent among

patients with chronic liver disease
• Nearly universal among patients awaiting
liver transplantation.
• Protein–calorie malnutrition (PCM)65–90%
of patients with advanced liver disease and in
almost 100% of candidates for liver
transplantation, frequently develop micro
nutrient deficiencies,
Liver disease
 Patients with cholestatic liver disease are
subject to calorie depletion, a deficiency in fat
soluble vitamins

 Patients with non cholestatic disease

predominantly experience protein depletion.
Nutritional Assesment
• Subjective Global Assesment
• Identify risk factor
• Recording effect
• Monitoring evaluation:
• Diet
• Clinic
• Physic/antropometry : triceps skin-fold thickness and
midarm circumference
• Lab/biokimia:
 concentrations of albumin and pre albumin could be low
Malnutrition in Liver Disease—Medical and
Nutritional Management
Nutritional therapy
• The goals of nutritional therapy are to improve
PCM and correct nutrient deficiencies (thiamine,
folate, and magnesium, Vitamin A, D, zinc) 
oral, enteral, parenteral methods, or a
combination of these modalities.
If a patient’s nutrient intake is inadequate, he/she
should be counseled to eat small, frequent meals
of nutrient-dense foods.
• Hirsch et al. the effects of nutritional
supplementation in patients with alcoholic
cirrhosis, receiving a daily supplement of 1,000
kcal and 34 g of protein (given as a casein-based
enteral nutrition product) 12 week
cont’
• The European Society for Clinical
Nutrition and Metabolism (1997) created
guidelines for meeting nutritional goals in
patients with end-stage liver disease.
Recommend initiation of enteral feeding when oral
intake is inadequate.
In patients with compensated cirrhosis, the
guidelines recommend that patients consume
25–35 kcal/kg body weight per day of nonprotein
energy and 1–1.2 g/kg body weight per day of
protein or amino acids.
 Patients with complicated cirrhosis associated with
malnutrition, nonprotein energy should be
increased to 35–40 kcal/kg body weight per day and
protein intake should increase to 1.5 g/kg body
weight per day.
Protein intake should decrease to 0.5–1.5 g/kg body
weight/day if stage I or II encephalopathy is present,
and to 0.5 g/kg body weight/day if stage III or IV
encephalopathy is present.
More recent evidence suggests that protein restriction
should not be recommended, even in the setting of
episodic hepatic encephalopathy.
 BCAAs, lactoalbumin, or maltodextrins.
cont’
• If complications of vitamin A deficiency (night
blindness)vitamin A supplementation,
generally at a dose of 25,000 units/day for 4–12
weeks.
• 25-hydroxy vitamin D supplementation, vitamin D3
(800 IU/day) and calcium (1 g/day).
• Zinc supplementation at doses of 600 mg/ day for
3 months has been shown to improve mental
functioning in patients with hepatic encephalopathy,
although other studies show conflicting
findings, and the role of zinc in treating hepatic
encephalopathy remains controversial.
Acute Hepatitis

• Small, frequent
• High Calori 2000-3000 cal
• Protein 2-2,5 g/kg/BB
• Enough fat
• Other nutrien like normal man
Cronic Hepatitis
• Malnutrition --- 35-40 cal, protein 1,5 g\
• Sonde  enteral feeding
• Nutritional therapy :
• Nutritional status with nitrogen > 10 g

• Protein BCAA

• If ascites diet Na =2,5 g, liquit -

• Nabati protein (TT pendek, non amoniogenic)

• Hepatotoxic –
• Constipasi - ; fiber, lactulosa
ASCITES AND OEDEMA

 2-4 grams of sodium and would exclude

canned soups and vegetables, cold cut meats,
condiments such as mayonnaise and tomato
sauce, dairy products, cheese and ice cream.
Most fresh foods are low in sodium. The best
salt substitute is lemon juice (which is salt
free)
CHOLESTASIS

• Acute : free fat

• Chronic : low fat, fat soluble vit, medium
chain triglyceride

 WILSONS DISEASE : copper (chocholate,

nuts, mushroom)
calorie
 Protein

 (0.8–1 g/kg) is probably adequate for

uncomplicated hepatitis or cirrhosis.
 to promote nitrogen balance : 1.2–1.3 g/kg
 alcoholic hepatitis, decompensated liver
disease and/or malnutrition is present,
protein needs may be as high as 1.5 g/kg
 hepatic encephalopathyBCAA,
lactoalbumin or maltodextrin supplement
 Electrolytes

 Sodium restriction is key in the treatment of

ascites and edema. Generally, a restriction of
1,500–2,000 mg sodium/day
 If hyponatremia is caused by excessive fluid,
fluid intake must be restricted, 1,000–1,500 ml
per day.
 If hyponatremia is due to an excessive loss
 of sodium, sodium must be supplemented
cautiously.
Vitamins and Minerals

 iron, zinc and selenium; B1, B6

 and B12, copper , fat soluble vit,
Manganese
 Folate, Iron
 Potassium
 Phosphorus
Other Supplements

 Alternative therapies are popular among

individuals with liver failure.
 The safety and efficacy of some of these
products are just now being evaluated.
Probiotics are being investigated as potential
therapy for hepatic encephalopathy.
Cont’

 Many herbal products are promoted to

people with liver dysfunction, but there is a
lack of safety and efficacy data.
 Some products that have been identified as
being hepatotoxic
 The two most popular herbal supplements
for liver disease are milk thistle and S-
adenosyl-methionine (SAMe).
Cont’
 Milk thistle contains silymarin, which supposedly
reduces free radical production and lipid
peroxidation associated with hepatotoxicity; it is
also promoted to be an antifibrotic agent.
 SAMe is a methyl donor for methylation
reactions and a participant in glutathione (an
anti-oxidant) synthesis.
 Meta-analysis and Cochrane reviews did not
show any beneficial effects of either of these
products for patients with liver disease.
Fulminant Hepatitis

• The important things, don’t become:

• 1. Hypoglicemia
• 2. Nitrogen balans negatif
• Must Suplai:
• 1. amino acid
• 2. Glucosa
Liver Transplantation

 Nutritional support
 Adequate calories and protein
 Supplement calories with medium chain
triglycerides
 Maintain levels of essential long-chain fatty
acids
 Treatment and/or prophylaxis for fat-soluble
vitamin deficiencies (vitamins A, D, E, and K)
Cont’

 Supplemental calcium and phosphate

when bone disease is present
 Prophylaxis for zinc deficiency
 Low-copper diet as poorly excreted
 Sodium restriction when ascites present
Summary

 Liver disorders—role of liver is so crucial to

overall health, its destruction is quite serious
 Goals—support maintenance of as much
normal liver function as possible
 Transplantation, if needed