Diet and nutrition therapy in pre-liver transplant patients

nutrition therapy in pre-liver transplant patients
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As the largest internal organ, liver plays several important roles in our body. Liver damage or disease can cause several health issues, and liver failure can be life-threatening. There are a number of causes and risk factors associated with acute and chronic liver diseases or failure.

Liver transplantation has revolutionized the treatment of liver diseases and it is the only option for many people having end stage liver disease (ESLD). This is a major surgery in which the damaged liver is replaced with a whole or part of healthy liver from a donor (living or deceased).

The patient and donor have to undergo a series of critical tests before the surgery. This includes compatibility test to prevent the chances of rejection and other complications post-operatively.

Liver transplantation is followed by a significant recovery period that requires full time care and many precautions. Although, post-operative period is important for the success of the transplant, the pre-liver transplant period is as important. One of the most crucial thing during this time is the nutrition and diet.

Liver failure due to cirrhosis or conditions such as fatty liver diseases needs a specific diet. Patients before liver transplant are put on a particular diet based on their condition to prevent further damage and ensure the body is healthy enough for the surgery. 

One of the common problems encountered by patients with end-stage liver disease is the protein and energy malnourishment. This can further increase the risk of morbidity, mortality and even influence the costs of the post-transplantation requirements.

Though, the liver transplant surgery cost in India is lower than most countries, the experts still consider the factors affecting the post-operative costs. 

The liver transplantation team will make careful nutritional assessment for Liver Transplant candidates. As the nutritional status of patients is important and have some influence on the LT related morbidity and mortality. During the preoperative stage, patient face the risk of losing the skeletal muscle mass, a condition called sarcopenia. This is known to have a detrimental impact on the liver transplant outcomes.

Therefore, managing the proper nutritional support during this phase of liver transplantation is necessary. Most patients and doctor prefer oral nutrition, but in certain cases a tube for enteral nutrition might be required to ensure the needed levels of energy is given.

This may also be supplemented by synbiotics, branched-chain amino acid supplements, micronutrients, immuno-nutrition formulas, fluid for electrolyte balance. The patient can also expect nocturnal meals, dietary counselling, and exercise along with rehabilitation.

However, there is yet no gold standard established for determining the quantity and type of malnutrition in such situations.

A suitable nutritional diet is planned on the basis of assessment, using the nutrition tools such as body composition analysis, anthropometry, subjective global assessment, and hand grip strength. These tools help doctors formulate a composite score which allows certain assessment of malnutrition in patients. 

Protein requirements

The studies have reported that patients with stable cirrhosis seem to require more protein, usually to the level of 1.2 g/kg per day as opposed to 0.8 g/kg per day required by normal people.

This is to maintain the nitrogen homeostasis but the main reasons for this phenomenon is not yet clear. The increased protein requirement might be due to the increased degradation of protein in the body caused by low plasma levels of insulin-like growth factor. 

Therefore, protein requirement and utilization by the body can be investigated by measuring the protein synthesis and degradation.

Some studies show that patients with liver cirrhosis who were on a balanced diet for an average of 2-4 weeks showed protein and energy intakes doubled. 

Vitamins

Another important part of the nutrition therapy for pre-liver transplant patients is the adequate amounts of vitamins. This is because LT patients may suffer from various kinds of vitamin deficiencies.

One of this is folate deficiency which is caused by a combination of factors including decreased intake, less absorption and losses from renal excretion along with poor hepatic storage.

This can be managed by folate and B12 supplementation, especially for patients with alcoholic hepatitis. It helps protect the undamaged hepatocytes and stimulate the repair or replacement of the damaged liver cells. The commonly recommended levels for folate supplementation is 1 mg/day orally.

Another problem is Vitamin B1 deficiency which is mostly linked to the damage to primary liver tissue such as alcoholic polyneuropathy and Wernicke’s encephalopathy.

The common supplementation level is 100 mg/day orally or subcutaneously for 2 weeks, which is then decreased  gradually to the amount in a standard multivitamin.

The dietitian will make a nutrition plan for the liver disease patient who will undergo liver transplantation. This will include several healthy food items and other eating options. The recommendations may include:

  • Lean meats, poultry and fish
  • Whole-grain or multi grain breads along with cereals 
  • A fiber rich diet
  • Low-fat milk and low-fat dairy products – just to maintain enough calcium
  • A low-salt and low-fat diet
  • Food processed as per the food safety guidelines
  • No alcohol
  • Drink adequate amount of water and other fluids to keep hydrated
  • Avoid certain food items such as grapefruit and grapefruit juice as it may have effect on some of the immunosuppression medications (calcineurin inhibitors)
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