CASE STUDY: ESLD WITH DIPS
Melanie Boney
Patient


61 year old man with multiple chronic diseases
Anthropometrics
 Height
75” / 190.5 cm
Pounds
Kilograms
Admit Body Weight
277.6
126.2
Usual Body Weight
300
136.4
Ideal Body Weight
184
83.6
 BMI:
34.75
Patient Medical History








IDDM
Peripheral Vascular Disease
 Left BKA (2008)
ESLD/Cirrhosis (2008)
 Secondary to Hepatitis C (1996) and Alcoholism
Cholecystectomy (1989)
Transient Ischemic Attack (2006)
Hypothyroidism
Hypertension
Microcytic Anemia
Patient Medical History
2/5/2010
 Admitted to SNF for
 Right
lower extremity
wound care
 New prosthesis fitting
with occupational
therapy for left BKA
(2008)

Monitoring of ascites
Medical Discoveries

Ascites
 Serial
 4.5

Large Paracentesis from 1/15 – 3/22
– 10 L removed
Hepatohydrothorax
 Repeat
 1.5

Therapeutic Thoracentesis 2/21 – 3 /18
– 2.0 L removed
Mild Encephalopathy
 Worsening
Major Depressive Disorder & Generalized
Anxiety Disorder
Active Medications











Acyclovir
Clobetasol
Digoxin
Diphenhydramine
Ergocalciferol
Ferrous Sulfate
Furosemide
Gabapentin
Insulin Aspart
Insulin Glargine
Lactulose











Levothyroxine
Morphine
Multivitamin
Omeprazole
Oxycodone
Polyethylene Glycol Powder
Propranolol
Quetiapine
Sprironolactone
Trazadone
Venlafaxine
Functions of the Liver

Metabolism of Macronutrients & Steroids

Storage / Activation of Vitamins & Minerals

Formation / Excretion of Bile

Filters & Detoxifies Blood
 Converts
Ammonia to Urea
Functions of the Liver
Cirrhosis




5 – 10% of
Population
Severe Damage to
Hepatic Cells
Inhibited Blood
Flow
Portal HTN &
Ascites
Portal Hypertension
Metabolic and Nutrition Complications

Hypoalbuminemia

Ascites
 Poor
appetite/early satiety

Hypoglycemia or Hyperglycemia

Vitamin & Mineral Deficiencies

Abnormal Electrolyte & Fluid Retention
 Intravascular
depletion of blood volume
Hepatic Encephalopathy
Endogenous and exogenous ammonia
Ammonia and metabolites easily cross BBB


 Irreparable
neural cell damage
 Waste products result in cerebral edema
Stage
Symptoms
I
Mild confusion, agitation, irritability, sleep disturbance,
decreased attention
II
Lethargy, disorientation, inappropriate behavior, drowsiness
III
Somnolent but arousable, incomprehensible speech,
confused, aggressive
IV
Coma
Nutritional Strategies to
Lower Ammonia

Protein Restricted Diet
 20-40g
↑
10g q3-5 days
 UL

of 0.8-1.0 g/kg
Severe Protein Restriction
 0-40g

/ day
/ day
Not Evidence Based
Normal Protein Diet

10 patients fed 1.2 g protein/kg/day

10 patients fed 0.5 g protein/kg/day


Protein catabolism ↑ in protein-restricted
patients
No significant difference in development of HE
ASPEN Guidelines on Nutrition for LD
“EN is the preferred route of nutrition therapy in
ICU patients with acute and/or chronic liver
disease. Nutrition regimens should avoid
restricting protein in patients with liver failure.”
ESPEN Guidelines on Nutrition for LD



“An energy intake of 35 – 40 kcal/kg/day and a
protein intake of 1.2 – 1.5 g/kg/day are
recommended.”
“Initiate normal food/EN within12–24 hours
postoperatively.”
“Initiate early normal food or EN after other
surgical procedures.”
MNT in ESLD

Protein-Energy Malnutrition

High protein catabolism



Poor Dietary Intake

Poor appetite/early satiety due to ascites



Small frequent meals
Sodium restriction
Abnormal Glucose Metabolism


High protein snacks
1.0 – 1.5 g/kg/day
Hypoglycemia or hyperglycemia
Nutrient Malabsorption / Deficiencies

MVM supplements
Medical Strategies to Lower Ammonia

Medications to Decrease Ammonia
 Laxatives
– remove GI ammonia
 Antibiotics

– decrease colonic ammonia production
Devices to Compensate for Liver Dysfunction
 Variceal
 DIPS
ligation, or banding
/ TIPS
Direct Intrahepatic Portocaval Shunt

A Transjugular Intrahepatic Portosystemic Shunt
(TIPS) is a stent that is placed in veins in the middle
of the liver which connects the portal vein to one of
the hepatic veins.
 This

procedure is performed without imaging guidance.
The Direct Intrahepatic Portacaval Shunt (DIPS) is a
modification of the TIPS procedure, using
intravascular ultrasound-guidance, combined with
fluoroscopy.
DIPS
DIPS
Fig. 1 Transfemoral
placement of IVUS probe
and puncture of portal
vein with modified RoschUchida Portal Access set
which has been placed into
IVC from a transjugular
route.
DIPS

Using the IVUS probe
to guide the needle
of a slightly modified
Rosch-Uchida set, the
needle is thrust
directly from the IVC,
through the caudate
lobe of the liver and
into the portal vein.
DIPS

Then using conventional catheter
and guidewire techniques, a shunt
is constructed from the IVC to the
portal vein using a Viatorr
endoprosthesis self expandable
stent-graft.
DIPS
Nutrition Assessment



Estimated energy needs: 2300 kcal/day
(28 g/kg for IBW)
Estimated protein needs: 100 g/day
(1.2 g/kg for IBW)
PES:
 Excessive
carbohydrate, fat and sodium intake related
to limited adherence to nutrition related
recommendations as evidenced by elevated CBGs,
ascites and obesity.
Physical Assessment

Overall Appearance
 Middle
aged male, pale gray skin

Pulmonary: Shortness of Breath

Digestive system
 Persistent
diarrhea, protuberant, abdominal pain
Biochemical Data: 2/8/10
Albumin
Prealbumin
Potassium
Sodium
Chloride
Phosphorous
Magnesium
Calcium
CBG’s
Hemoglobin A1C
2.6
11.3
4.7
136
98
4.4
2.0
8.0
213-308
7.2
Nutrition Intervention: 2/11/10


Diet: Regular
Nutrition Education
 Low
Sodium
 High Protein
 Diabetes Education

Patient declined
 Weight
Loss
 Patient
requested
 Goal wt. 225 lbs
Biochemical Data: 2/22/10
Albumin
Potassium
Sodium
Chloride
Phosphorous
Magnesium
CBG’s
2.4
3.9
132
93
4.4
1.7
183-287
Nutrition Intervention: 2/23/10


Diet: Mild Sodium
Nutrition Education
 Low
Sodium
 High Protein
Nutrition Intervention: 3/3/10


Diet: Mild Sodium
Nutrition Counseling
 Patient
 Wt.
discussed his strategies for weight loss
255 lbs
 Excessive fluid restriction
 Ice cream or pudding 2 – 3 x’s /day
DIPS Surgery: 3/22/10
Nutrition Intervention: 3/24/10



Diet: Mild Sodium
Juven BID
Nutrition Education
 High
Protein
 Low Sodium
 Low Carbohydrate
 Fluid Restriction
Admitted to PVAMC





Diet: Diabetic
Discharged home 4/2/10
Admitted for worsening hepatic encephalopathy
Treated from 4/7/10 to 4/14/10 at PVAMC
Transferred back to SNF
Nutrition Intervention: 4/15/10


Diet: Mild Sodium, Diabetic
Nutrition Counseling
 High
protein
 Small frequent meals
Surgery: 4/23/10

Modifications to Existing
DIPS
Outcome

Renal function remains
 Normal


BUN & Creatinine
Patient’s mental status continues to decline
His nutrition status continues to decline
 Currently

on a 1800-2000 kcal restriction
Awaiting approval for DIPS reversal
References

Image http://www.360oandp.com/is-a-c-leg-right-for-you.aspx

Davis GL. Thoughts on Nutrition and Liver Disease. NCP. 2006;21:243-244.

Summar ML. Urea Cycle Disorders Overview. Gene Reviews. 2005; Retrieved from
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=gene&part=ucd-overview

Image http://www.beliefnet.com/healthandhealing/getcontent.aspx?cid=11959

Image http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=BB532D8A-43CB-416C-9FD2A07AC6426961&GDL_Disease_ID=C8BD9205-E51B-4186-B4E4-B5087B21F9EA

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in Clinical Nutrition and Metabolic Care. 2007;10297-102303.

Shenkin A. Serum Prealbumin: Is It a Marker of Nutritional Status or of Risk of Malnutrition? Clinical Chemistry.
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
McClave SA, Martindale RG, Vanek WV, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G. Guidelines for
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
Plauth M, Cabre E, Riggio O, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr.2006; 25:285 -294.

Córdoba J, López-Hellı ́n J, Planas M, Sabı ́n P, Sanpedro F, Castro F, et al. Normal Protein Diet for Episodic Hepatic
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
DiCecco SR, Fracisco-Ziller N. Nutrition in Alcoholic Liver Disease. NCP. 2006;21:245-254.

Intravascular US-guided Direct Intrahepatic Portocaval Shunt with an Expanded Polytetrafluoroethylene-covered StentGraft. Radiology. 2008;246:306-314.

Rose JDG, Pimpalwar S, Jackson RW. A New Stent-graft for Transjugular Intrahepatic Portosystemic Shunts. British Journal
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