Emily Rohan
KNH413 – Diet Instruction
Hepatic Failure, Coma
1.
Description of patient and diagnosis.
26-year old female, Cynthia Applebottom is admitted to McCullough Hyde Hospital with increasing symptoms of liver disease 2 years after being diagnosed with hepatitis C virus (chronic liver disease). A liver biopsy and CT scan diagnose Cynthia with chronic liver failure, or Cirrhosis. A day after admittance, Cynthia falls in to a coma and a liver transplant is immediately ordered. The transplant was successful and
Cynthia has been recovering for 4 days. She can intake food orally but her chief complaint is that she doesn’t have a big appetite. She has lost another 3 pounds since the surgery. She had lost 6 pounds unintentionally prior to the surgery.
Temp: 96.5
Pulse: 80
Blood Pressure: 122/76
Height: 5’8”
Current Weight: 121 lbs
Usual Body Weight: 130 lbs (pre-surgery)
BMI: 18.5 (lower end of normal, almost underweight)
2.
Discussion of the Disease
There are many types of liver disease and some are more serious/life threatening than others. Jaundice, Portal Hypertension/Ascites, Hepatic Encephalopathy, Hepatitis
(A,B,C,D,E) , Cirrhosis are all diseases of the liver and all can lead to liver failure and/or a coma if left untreated. The liver has many functions including the removal of by-products from the digestion of food, the absorption of food and proteins necessary for normal blood consistency and clotting as well as other molecules involved in metabolism. Initial damage to the liver can elevate certain enzymes in the blood due to leakage from the liver. Measuring blood glucose, cholesterol, bilirubin, albumin, aminotransferases, alkaline phosphatase, and prothrombin time will help evaluate liver function. When the liver fails some or all of these substances can decrease. A bile acid test may also be used to further test liver failure. a.
Etiology
The pathophysiology of hepatic encephalopathy (HE) is very similar to the pathophysiology of liver failure because HE is a syndrome of impaired mental status and abnormal neuromuscular function that occurs from major liver failure. Ammonia is thought to be a direst toxin to the brain that is generated from the catabolism of proteins, amino acids, purines, and pyrimidines. Liver disease interferes with the detoxification process and shifts ammonia metabolism to skeletal muscle and then used to convert glutamate to glutamine instead of being synthesized, absorbed, and transported in the intestinal venous blood to the lever and then metabolized to urea. Mercaptans, ammonia, tyramine, octopamine, beta-phenylethanolamines, manganese, and gamma-aminobutyric acid also accumulate in liver failure as well as in HE. The symptoms of hepatic coma are often corrected by

decreasing endogenous ammonia production. Aromatic amino acids, such as tryptophan, tyrosine, and phenylalanine, are elevated in the brains of patients with liver failure and HE.
Liver failure means that the liver is losing or has lost all of its function. It is life threatening and demands urgent medical care. The first symptoms usually seen in liver failure patients are nausea, loss of appetite, fatigue, and diarrhea.
As liver failure progresses, these symptoms become more serious and severe to the point where the patient may become disoriented or confused and the risk for coma or death increases. If the liver is not responding to any treatment the only option is a liver transplant. When liver failure occurs as a result of cirrhosis, this essentially means the liver has been failing gradually for a portion of time and is then termed Chronic Liver Failure (CLF). CLF can also be caused by malnutrition. Cirrhosis represents the end of the pathophysiology spectrum for a wide variety of chronic liver diseases in which health tissue is replaced by scar tissue, blocking the blood flow through the organ and resulting in the loss of liver function.
In comparison, acute liver failure is failure of the liver that occurs suddenly, as little as 48 hours and is usually due to poisoning or a medication overdose. b.
Diagnostic Measures
Diagnosing Hepatitis C Virus:
There are several blood laboratory tests that are used to diagnose HCV infections, with the most common once being measurement of antibodies to hepatitis C virus (anti-HCV), negative tests for antibodies to HAV and
HBV help confirm the diagnosis as well.
Diagnosing Cirrhosis:
No serologic or radiographic test can accurately diagnose cirrhosis but a significant correlation has been demonstrated between persistently elevating liver function tests and biopsy-proven underlying hepatic disease.
Symptoms of cirrhosis include fatigue, weakness, nausea, poor appetite, jaundice, dark urine, light stools. Steatorrhea, itching, abdominal pain, bloating, and malnutrition. Vitamin and mineral deficiencies can cause or contribute to depressed hematocrit and hemoglobin values. Decreased vitamin K values are due to malabsorption and the inability of the liver to synthesize protein clotting factors which can result in bleeding and bruising. c.
Treatment i.
Medical, surgical and/or psychological treatment
The primary medical treatments for cirrhosis are abstention from alcohol, treatment of HCV, or other complications depending on patient, and nutrition therapy.
The most common liver disorders that require a liver transplant include chronic active hepatitis, cirrhosis, and biliary-related disorders. After transplant, all patients require immunosuppressive drugs to prevent rejection of the new liver. ii.
Medical Nutrition Therapy

Nutrition Concerns for patients with liver disease/liver failure:
-decreased abdominal room due to ascites, if present
-delayed gastric emptying
-decreased appetite
-poor nutrient absorption
-decreased bile production = low fat absorption
-diarrhea
-altered mental status/encephalopathy
The main goal for patients before transplant is to lessen the effects of malnutrition and complications of liver disease.
Nutrition concerns post-operative liver transplant:
The risks for preoperative malnutrition, surgical stress, post-interventional complications, post-operative protein catabolism, fasting periods, and side effects of immunosuppressant medications suggest the need for early nutrition support after the transplant. After recovery, patients are more susceptible to food-borne infections as a result of the immune-suppressing medications.
Nutrition concerns for post-liver transplant:
-increased energy expenditure
-inadequate energy intake
-inadequate oral food/beverage intake
-inadequate protein-energy intake
-malnutrition
-inadequate vitamin/mineral intake (thiamin)
-altered GI function
-impaired nutrient utilization
-underweight
-altered nutrition-related laboratory values
-food-medication interactions
-food and nutrition related knowledge deficit
-involuntary weight loss
Recommendations
After transplant, most nutritional deficiencies and metabolic disturbances common in patients improve. The main goal is to meet the needs for healing and preferred nutrition support should either oral or enteral.
Fluid Intake:
-avoid overhydration  6-8 cups a day is adequate
-avoid dehydration since it can lead to renal problems
Calorie Recommendations:
15-30% above basal needs
Cynthia’s Calorie Intake (Mifflin St. Jeor)

REE= 10 (55kg) + 6.25 (172.3cm) – 5 (26yrs) – 161
REE= 1336
REE x Activity Factor (1.2 for confined to bed) x Injury Factor (1.2 for surgery)
Total Energy Requirements: 1336 x 1.2 x 1.2= 1924kcal
1924 x 15%= 288kcal extra 1924 x 30%= 577kcal extra
RANGE: 2210kcals to 2500kcals
Protein Recommendations:
1.5-2.0 g/kg
Cynthia’s needs:
55kg x 1.5g PRO= 82.5 grams
55kg x 2.0g PRO= 110 grams
RANGE: 82.5 – 110 grams of protein per day
Carbohydrate Recommendations:
To prevent/manage hyperglycemia it is recommended that the patient decreases simple sugars and have carbohydrates provide 50-60% of total kcal. It is also recommended to restrict sodium intake by 2-4grams.
Cynthia’s needs:
Cynthia is recovering well so I will use the lower value of kcal to calculate CHO needs:
2210kcal x .50= 1105kcal from CHO / 4 grams per kcal= 276 grams CHO
2210kcal x .60= 1326kcal from CHO / 4 grams per kcal= 330 grams CHO
RANGE: 276-330 grams of Carbs per day
Fat Recommendations:
Some people with liver disease have problems digesting and absorbing fat. The fat that is not digested is eliminated through bowel movements. Fat present in the feces is a nutritional concern and the patient should be put on a low-fat diet.
Other Nutrient Recommendations:
Calcium supplements along with a multivitamin may be recommended post surgery to help maintain bone health and ensure overall nutritional needs are being met.
Patient should be educated on food safety because of their increased susceptibility to food-borne illnesses. iii.
Prognosis- (supported by professional source)
Patients with cirrhosis, or any end-stage liver disease, average 1- and
5- year survival rates are 80% - 50% respectively. The clinical tools used to determine prognosis with patients with cirrhosis are the Child-Turcotte-
Pugh (CTP) classification and the prognostic model for end-stage liver disease (MELD). MELD score is based on three blood tests: international normalized ration (INR) which tests the clotting tendency of the blood, bilirubin which tests the amount of bile pigment in the blood, and finally creatinine which tests kidney function. Essentially, the prognosis depends

on the cause of the hepatic failure and two main factors involved in determining prognosis are etiology and coma grade upon admission.
After liver transplant, overall patient survival rates that were at one and five years immediately increase to 86.4% and 72.9% respectively.
PATIENT CHART
Patient: Cynthia Apple Bottom

Anthropometrics:
Temp: 96.5
Pulse: 80
Blood Pressure: 122/76
Height: 5’8”
Current Weight: 121 lbs
Usual Body Weight: 130 lbs (pre-surgery)
BMI: 18.5 (lower end of normal, almost underweight)
Chief complaints post-op:
The transplant was successful and Cynthia has been recovering for 4 days. She can intake soft foods orally but her chief complaint is that she doesn’t have a big appetite.
She has lost another 3 pounds since the surgery. She had lost 6 pounds unintentionally prior to the surgery.
Nutrition:
General: Poor appetite for the past 3 weeks. She drinks almond milk for calcium supplement for breakfast everyday. Lunch is either a small salad or soup with crackers and iced tea. Dinner is usually at home and consists of a piece of plain chicken or fish with a vegetable and rice.
Current diet intake: ice chips or sips of orange juice. Breakfast: Soft scrambled eggs with
½ slice of wheat toast. Mid day: Soft noodles with butter. Dinner: None- no appetite.
Current diet order: mostly soft, 4 grams sodium restriction, high calorie, frequent meals
(4-6 x day)
Food purchase/prep: herself
Vitamin/Mineral Intake: 600 mg Calcium with 400 IU vitamin D, multivitamin/mineral daily
Instruction Materials
Why is the liver important?

The liver is the second largest organ in your body and is located under your rib cage on the right side. It weighs about three pounds and is shaped like a football that is flat on one side.
The liver performs many jobs in your body. It processes what you eat and drink into energy and nutrients your body can use. The liver also removes harmful substances from your blood.
Why is nutrition important after liver transplantation?
Nutrition plays a key role in your recovery after liver transplantation. As with any surgery, adequate calories, protein, vitamins, and minerals are needed for wound healing. Also, your nutrient and diet needs may change if you have complications and/or side effects from your medications after your transplant.
Once you have successfully recovered from the early stage after transplant (ex. your appetite is back to normal, your weight is stable, and your wounds are healing well) then you should change to a diet that is low in saturated fat and high in fiber, fruits, and vegetables. This type of diet will help reduce risks for other chronic diseases including heart disease and diabetes. Always discuss your individual dietary needs and concerns with your dietitian or doctor.
It is important to maintain a healthy weight. Obesity, gaining an unhealthy amount of excess fat, increases your risk of chronic diseases and can damage your new liver.
Eating a healthy diet helps the liver to do its functions well and to do them for a long time.
Eating an unhealthy diet can lead to liver disease. For example, a person who eats a lot of fatty foods is at higher risk of being overweight and having non-alcoholic fatty liver disease.
For people who have liver disease, eating a healthy diet makes it easier for the liver to do its jobs and can help repair some liver damage. An unhealthy diet can make the liver work very hard and can cause more damage to it.
Where should my calories come from?
You should eat enough calories to prevent muscle wasting and allow for gradual regaining of lean body weight that is often lost with severe illness before transplant and during hospitalization (bed-rest) after transplant. Choose nutrient dense foods (dairy, whole grains, plant foods) instead of foods considered “empty calories” (ex. sodas, candy). If appetite is poor, broaden your scope of food choices to allow for food preferences. Fruits and vegetables need to be part of your diet to provide enough vitamins and minerals.
Where should my protein be coming from?
Protein is important to promote healing and muscle gain.
Suggestions of animal based high protein sources:
-fish
-poultry
-egg whites
-eggs with yolk no more than 4 times per week
-dairy products-milk, cheese, yogurt
-red meats- pork, beef, veal
Suggestions of plant based high protein sources:
-unsalted nuts
-peanut butter
-soy products
-dried beans, lentils
Choose lean protein foods more often and prepare them using lean cooking methonds like drilling or baking rather than pan frying. Avoid using iron pans.
How can I avoid hyperglycemia?

Hyperglycemia is a side effect of the medications given after transplantation. To prevent or manage this condition, foods high in simple sugars should be limited. These include:
-sugar
-molasses
-doughnuts, pastries, sweet rolls
-pies, cakes, cookies
-honey
-syrups
-jam, jelly, marmalade
-soft drinks (diet sodas are acceptable)
-candy, chocolate
-ice cream, frozen yogurt
-jell-o
-other sweetened beverages (juices, teas)
Blood sugar levels should be monitored and if you develop high blood sugar you diet may need to be modified to the following guidelines:
-carbohydrates should be high in fiber- consume more whole grain products, legumes, vegetables instead of refined white breads and cereals.
-Limit fruits to one serving per meal. One serving = ½ cup chopped or canned or one medium whole
-eat often, avoid skipping meals. Each meal and/or snack should include some high quality protein
How much sodium am I allowed?
Some medications such as prednisone can cause your body to retain sodium and water. This can then cause increased blood pressure. To help avoid this, it is best to restrict salt intake. The “No Added Salt” diet, which is usually recommended, suggests eating less than 3000 mg of sodium each day. To follow these recommendations, you should:
1.
limit salt when cooking, Use herbs and spices for flavor instead.
2.
Do not add salt after food is prepared
3.
Avoid or limit the following foods a.
High salt/canned soups, processed meats, fast food items, salted snacks (i.e. pretzels, crackers, potato chips, etc.
4.
Condiments
What else can help benefit my health after transplant?
EXERCISE.
Long periods of inactivity and/or bed rest causes loss of muscle mass and strength (including strength of the heart) and limits your ability to perform exercise. A successful transplant does not automatically return you to normal physical activity. For muscles to regain their function and strength, they must be used regularly.
Many people after transplant have high blood pressure, high cholesterol, and gain fat weight. All of these increase your risk of heart attacks or stroke.
There is enough scientific evidence to say that regular physical activity:
•Decreases risk of death from heart disease.
•Prevents or delays the development of high blood pressure.
•Reduces blood pressure in people who already have high blood pressure.
•Keeps muscles and joints strong and functioning.
•Helps bones develop during childhood and helps adults prevent osteoporosis (thinning of the bones).
FOOD SAFETY AND SANITATION
Post liver transplant surgery you are more susceptible to food borne illnesses so continuing food safety practices is essential.
DRUG/NUTRIENT INTERACTIONS:
You are taking immunosuppressant medication. There are many potential food-drug interactions that can occur. The following table will guide you:

Immunosuppressant Drug Generic Name Possible food-drug interaction
Cyclosporine, tacrolimus No Potassium supplement or salt substitute, caution with grapefruit
Anorexia, diarrhea, increase glucose, esophagitis, steatorrhea
Azathioprine
Rapamune
Mycophenolate mofetil
Diarrhea, steatorrhea, negative nitrogen balance
Increased cholesterol, hypertriglyceridemia
Take on empty stomach, anorexia, stomatitis, dyspepsia, abdominal pain, colitis, diarrhea, constipation
Should I be worried about potassium toxicity?
If you are taking Cyclosporine or Tacrolimus, these can increase your blood potassium levels.
Abnormal blood potassium levels can cause problems with muscle and heart function. Below is a list of food items that are high in potassium. If you are taking these medications you will be asked to limit the intake of these items.
-Apricots, avocados, bananas, dried fruit, melons, oranges, nectarines, peaches
-leafy greens, pumpkins, potatoes, split peas, dried beans, lentils, tomatoes
-orange juice, prune juice, tomato juice, v-8 juices
-milk and dairy, peanut butter, nuts, chocolate
SAMPLE 1 DAY MENU
Breakfast
3 scrambled egg whites
2 pieces soft wheat bread
AM Snack Lunch
½ cup Oatmeal 2 oz. turkey breast lunchmeat (low sodium)
1 cup almond milk
1 slice Swiss
Cheese
½ cup apple sauce
PM Snack
½ cup cottage cheese
Dinner*
Whitefish with
Tomato Mousse and Fresh
Herbs
Fresh fruit/berries
2 TBSP hummus
8 crackers no salt
Lettuce, Tomato Peanut butter
Kale Blueberry and
Pomegranate
Salad
1 cup vanilla greek yogurt
1 cup orange juice
2 slices whole grain bread
Side Salad with low fat dressing
*recipes attached
RECIPES ADOPTED FROM “HEALTHY RECIPES” OF THE AMERICAN LIVER
FOUNDATION

Whitefish with Tomato Mousse and Herbs
Serves 4
1-pound White fish fillet (halibut, cod, etc.)
10 large, ripe tomatoes
1 clove of garlic
1⁄2 cup fresh or dried herbs (chervil, tarragon, basil, etc.) fine chopped
Salt and pepper to taste
DIRECTIONS:
-Cut the fish into four equal portions of 4 ounces each, season with salt and pepper, keep refrigerated. -Cut tomatoes in half and remove seeds but save the juice. Using a blender, puree the tomatoes and garlic. Place the tomato puree in a saucepan, and simmer over medium heat for about 20 minutes.
-After cooking gently remove the red tomato mousse that is forming at the top and reserve draining in a strainer lined with a coffee filter adding the additional liquid to the rest and stain it though a coffee filter as well. What happens when the puree is cooking it separates and forms a red thick puree on the top and a clear broth on the bottom.
-Broil the fish under the oven broiler to desired doneness.
-Place the fish into a shallow bowl and pour tomato broth on top. Garnish with tomato mousse, and fresh herbs.
KALE, BLUEBERRY AND POMEGRANATE SALAD

Kale is usually thought of as a green for cooking, but in this recipe, it’s used as a salad green, one with a lot more texture than lettuce. Its hardiness means that the leaves won’t wilt after the salad is dressed. Kale’s pleasant bitterness is nicely balanced by the sweetness of the blueberries and the tartness of the pomegranate seeds. This salad is rich in brain-boosting foods: Kale is an excellent source of flavonoids and vitamin C, blueberries and pomegranates are high in antioxidants.
Serves 4
3 bunches Kale, stemmed and chopped
1 cup fresh blueberries
2 medium carrots, peeled and shredded
1⁄2 cup pomegranate seeds
1/3 cup pumpkin seeds, toasted
1/3 cup sliced almonds, toasted
1 tablespoon chopped fresh mint leaves
1⁄2 cup Soy-Seasame Vinaigrette
Salt and freshly ground black pepper
DIRECTIONS:
Combine the kale, blueberries, carrots, pomegranate seeds, pumpkin seeds, almonds, and mint in a medium bowl and toss well.
Drizzle with the vinaigrette and toss again.
Season to taste with salt and pepper and serve right away.
WORKS CITED

Healthy Recipes. American Liver Foundation. July 2013. Retrieved from: http://www.liverfoundation.org/downloads/alf_download_1068.pdf
Liver Transplant Patient Handbook. UCSF Medical Center. 2011. Retrieved from: http://www.ucsfhealth.org/pdf/liver_transplant_manual.pdf
Liver Disease Diet. 2014. Retrieved from: http://www.drugs.com/cg/liver-diseasediet.html
Liver and Wellness. American Liver Foundation. 2009. Retrieved from: http://www.liverfoundation.org/downloads/alf_download_729.pdf
Nutrition Therapy and Pathophysiology, Nelms, pages 447-460.
The Progression of Liver Disease. American Liver Foundation. October 2011. Retrieved from: http://www.liverfoundation.org/abouttheliver/info/progression/