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Liver and Liver Transplant Program Nutrition Guidelines

Liver and Liver Transplant Program

POLICY/PROCEDURE TITLE:

Nutrition protocol DISTRIBUTE TO:

All supporting staff for the liver

program radiology, pathology

[ X] ADMINISTRATIVE [X ] CLINICAL

PAGE 1 OF 6

RELATED TO:

[ x ] Patient Care [ ] JCAHO

[x ] Nursing Practice [ ] Title 22

[ ] Med Ctr Policy (MCP) Stds [ ] QA

[ ] Other [ ] UNOS

Effective Date: Revision Date: NA

Updated: NA Unit/Service Line/Department of Origin:

Liver and Liver Transplant Program Other Approval: NA Policy/Procedure Committee Approval:

Completed

I. Obesity Introduction Obesity is a major medical problem, defined by a body mass index (BMI) of 30 kg/m2 or greater. Obesity may result in technical challenges to liver transplant surgery, increase risk for wound dehiscence (1), increase infectious complications (2, 3), result in a longer hospital stay (4), increased cost (5) and decreased survival following liver transplant (3, 5). The rate of primary liver graft nonfunction is also increased in patients with BMI >35 kg/m2 (5). Obesity is a recognized risk factor for multiple medical problems that may significantly impact survival and quality of life in the liver transplant population. These include diabetes, hyperlipidemia, cardiovascular disease, and cancer. Pre-transplant obesity is an independent risk factor for development of metabolic syndrome following liver transplant (6). Classes of over weight and obesity defined by the World Health Organization: BMI 25-30 kg/m2 overweight BMI 30-35 kg/m2 obese BMI 35-40 kg/m2 severely obese (morbid) BMI >40 kg/m2 very severely obese (super morbid) AASLD practice guidelines published in 2005 state that morbid obesity (defined in this paper as BMI >40 kg/m2) should be considered a contraindication to liver transplant (7).

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Assessment & Management of the Obese Patient in Liver Transplant Clinic

1. Obtain current height, weight and historical body weight and BMI should included in each patient’s chart. Patient height needs to be measured by clinic staff (patient report of height is not adequate).

2. Assess patient’s fluid status. Evaluate if the patient has fluid retention from

ascites and/or edema. Check abdominal ultrasound or cross sectional imaging results to verify the presence of ascites or interstitial edema, if not readily apparent from physical exam. Establish an estimated dry weight for the patient if volume overloaded or use the patient’s current weight if no fluid retention is present per physician assessment.

3. Calculate patient’s body mass index using estimated dry weight or current weight

(see above) and measured height without shoes If the patient’s BMI is greater than 35 kg/m2, The patient will be asked to

sign a weight loss contract and the surgeon will help to determine if the patient should be listed for transplant based upon the patient’s body habitus and abdominal and rib structure and the transplant team will help to assess obesity-related co-morbidities that may affect transplant candidacy. Patients accepted for listing with a BMI greater than 35 kg/m2

will not be activated unless the team reaches a consensus on the individual patient’s status or until the established goal weight is achieved and maintained for 90 days.

i. If at least 2 transplant surgeons agree that a patient with BMI 35-40 kg/m2 is transplantable based upon their body habitus (and transplant candidacy is not otherwise affected by medical co-morbidities via the hepatology team) then a patient may be activated before weight loss occurs to reach BMI <35 kg/m2. In these cases, patients will still be advised to work toward achieving their goal weight while awaiting transplant. 1. These patients will be considered for combined LT and

vertical banded gastroplasty

If the patient’s BMI is greater than 40 kg/m2, or These patients will be considered for combined LT and vertical banded gastroplasty

Or the patient will not be placed on the liver transplant waiting list. The patient will be asked to sign a weight loss contract (see below) in order to attain a goal weight deemed to be acceptable for reconsideration for transplant candidacy. Once this goal weight is achieved, the patient’s case will be re-discussed with the transplant selection committee.

i. Patients who have a BMI >40 kg/m2 with coronary artery disease or significant diabetic nephropathy requiring a dual organ transplant will not be considered as candidates for transplantation at SJMC (8-10). These patients should be referred to an alternate center for consideration for liver transplantation.

4. A goal weight will be established to achieve a BMI <35 kg/m2, and target a healthy BMi in the 24-26 range (using a dry weight) will be advised for all patients and each patients will be asked to sign a weight loss contract. The patient will be asked to lose at least 20% of their excess weight within 6 months of signing

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their weight contract to demonstrate compliance. The hepatologist and registered dietician will monitor compliance at each visit. For example, a patient weighing 250 lbs with a goal weight of 180 lbs (to achieve BMI <35 kg/m2) will need to lose 14 lbs (250-180=70; 70 x 0.2 = 14) within 6 months to remain listed for LT. Subsequently, patients will need to have lost a range of 30- 50% of excess weight at 12 months to remain listed. Example: 250-180 = 70lbs; 70 x 0.5 = 35 lbs.

A weight contract will be signed by the patient at the time of their dietary

consultation i. This contract can consider <1200 calories per day due after an

assessment of risk of malnutrition is completed. ii. At least 1.2-1.5 gm/kg of protein intake per day is

recommended in the absence of concomitant renal disease. i. The contract will include expectations regarding exercise (see

below)

When the patient meets the established goal weight, the patient will be activated for liver transplant.

If the patient is not able to meet weight loss goals, the patient will not be

considered a candidate for liver transplant. The patient will be informed of their failure to meet their weight loss target (in person and in writing), and will be removed from the liver transplant list after one year of attempted weight loss.

Patients will be closely monitored by the liver transplant dietician, both in

clinic and by phone or secure Email messages between clinic visits, to facilitate success with their dietary modification and ensure adequate protein and caloric intake. Notes from outside dietician visits will be scanned into the media section of the EHR so as to remain part of the patient’s medical record.

5. In addition to meeting with the liver transplant dietician, a weight loss group, such

as Weight Watchers, Jenny Craig, Nutrisystem, or other acceptable weight loss plan, may be recommended to patients in selected cases.

Any weight loss group or program is subject to review by the liver

transplant dietician in order ensure safety

6. The patient will be required to exercise and have a fitness plan tailored to their medical condition. Recommendations should be 30 minutes of exercise at least 5 days per week.

If the patient has physical limitations that preclude exercise, then referral to physical therapy will be strongly recommended.

7. Patients may be referred for bariatric surgery (vertical banded gastroplasty) if:

BMI >40 kg/m2 or ≥ 35 kg/m2 with associated comorbidity** They have failed prior weight loss regimens They are an acceptable surgical risk and Child’s A cirrhosis.

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Or at the time of LT if there is center that will accept the patient i. Patients will preferentially have bariatric surgery at a center

that is accustomed to operating on patients with cirrhosis. **Coronary artery disease, type 2 diabetes, obstructive sleep apnea, obesity hypoventillation syndrome, Pickwickian syndrome, NAFLD/NASH, hypertension, dyslipidemia, pseudotumor cerebri, GERD, asthma, venous stasis disease, severe urinary incontinence, debilitating arthritis, or considerable impaired quality of life From AACE/TOS/ASMBS Guideline (11)

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Weight Loss Contract

I understand that I am by calculated BMI, Body Mass Index (Website MedCalc)

Overweight: ______ BMI 25-29

Obese: _______ BMI 30-34

Morbidly obese: _______ BMI 35-39

Supermorbid obese: ______ BMI 40 +

I understand that I am at high risk of dying from: liver failure, cancer, liver

cancer, heart disease, kidney failure or stroke: ____________

I am committed to a stringent long-term goal of attaining a healthy weight:

_______________________ BMI target is 24 for Caucasians/other ethnic groups, BMI

target is 22 for Asians and Pacific Islanders

I hereby am committed to a weight loss program that works: _________

My Contract to lose weight includes:

1) Nutrition consult that I will arrange with my primary care provider

2) I will keep a Log book with within a paper folder or using

http://www.myfooddiary.com/ to record the following each day:

a. daily weights

b. daily calories counts

In addition: I will document

c. 3 hours of exercise per week

i. I will measure my heart rate with a target to be over 100

for 3 hours each week

ii. I will learn to take my heart rate or obtain and use a heart

rate monitor

3) I will Initiate an immediate 40 % calorie restriction

4) I will eat only 5 small meals per day of 150 to 200 calories each and I

will:

a. Use tea cup saucers for all meals, no second servings

b. Eat “high” protein, 80 – 100 gm per day

c. Consume moderate carbohydrate

d. Decrease to a American Heart Association low fat diet

5) I will not drink liquids from plastic bottles, and I will use only glass

storage containers (see information on bis-Phenols (BP) (see website:

“Nova”, keyword “epigenetics”), most plastics contain some form of BP

6) I will not drink alcohol

7) I will Utilize the “Hungry is healthy” motto

8) I will intake: Fiber supplements: 3 times per day with meals

9) I promise to return a Signed and dated weight contract

10) I will post the weight loss contract in my:

a. Bedroom

b. Bathroom

c. Kitchen

______________ ___________________ ____________________

Name Signature Date

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II. Underweight Sarcopenia

Protocol for the Pre-Liver Transplant Underweight Patients Protein energy malnutrition (PEM) is prevalent among patients with cirrhosis of all etiologies. Even among those with compensated disease (Child class A), protein depletion is reported approximately 20% of the time and among those with decompensated disease, significant nutritional deficiencies are nearly universal. While malnutrition is not captured in the MELD score, it is an independent predictor of poor prognosis in cirrhosis and poor outcomes after liver transplant (12-15). Definitions according to World Health Organization: BMI <18.5 kg/m2 Underweight BMI 17.00-18.49 kg/m2 Mild thinness BMI 16.00-16.99 kg/m2 Moderate thinness BMI < 16 kg/m2 Severe thinness Causes of malnutrition in ESLD include the following (16):

1. Dietary insufficiency: anorexia, nausea, vomiting, early satiety, dysgeusia, and unpalatable diet (sodium restriction)

2. Maldigestion/Malabsorption: exocrine pancreatic insufficiency, cholestasis, drug-induced diarrhea (lactulose)

3. Altered metabolism: catabolic state in setting of infection, GI bleeding or other acute illness, increased proinflammatory cytokines (TNFglucose homeostasis

4. Iatrogenic: procedure-related prescribed fasting, repeated large volume paracentesis

As important as nutritional status is in this patient population, nutritional assessment faces particular challenges in advanced liver disease and there is currently no universally accepted methodology. The subjective global assessment (SGA) (17) has been validated in multiple patient populations and seems to perform reasonably well in liver transplant candidates (15, 18), though requires a registered dietician or other trained provider to perform. The most widely recognized anthropometric measure of nutrition status, body mass index (BMI), may perform particularly poorly in cirrhotics due to fluid retention (ascites and edema). It is possible, however, to utilize BMI in patients with volume overload by estimating the amount of excess fluid (19). Other anthropometric measures that may be informative, but are rarely performed, include triceps skin fold thickness and mid-arm muscle circumference (see table for guidelines) (16). In addition to these tools, functional assessments may provide another means of identifying patients at increased risk for poor outcome. Handgrip strength, using a dynamometer, appears to be highly sensitive for PEM in patients with cirrhosis, predictive of increased risk for complications in cirrhosis, and a marker of risk for longer ICU stay and higher risk of infection after liver transplant (13, 20). Frailty is defined as “the biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes” (21). One aspect of frailty is muscle loss or sarcopenia. This was evaluated among liver transplant candidates in a study performed at the University of Michigan that measured psoas muscle area with CT scan and found strong association

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between psoas area and post-transplantation mortality (hazard ratio=3.7/1,000mm2 decrease in psoas area; p<0.0001) (22). Gait speed (time, in seconds, to walk 5 meters) has been reported to be an independent predictor or morbidity and mortality in elderly patients undergoing cardiac surgery (23). Similar data for gait speed or ability to ambulate 100 feet and liver transplant outcomes are not available in the published literature at this time.

The major goals of pre-transplantation nutritional therapy are to first correct any macro- and micro-nutrient deficiency and later to prevent further nutrient and protein depletion. Nutrition support therapy should be inclusive of energy requirement (calories), protein 100 gms per day, vitamins, minerals, and trace elements. Patients with liver cirrhosis exhibit early onset of gluconeogenesis after short-term fasting. Patients with portal hypertension have documented fat malabsorption made worse by cholestasis. This accelerated metabolic reaction to starvation may underlie their increased protein requirements and muscle depletion. Provision of a nighttime feed (supplemental nocturnal tube feeds) to patients with cirrhosis results in body protein accretion equivalent to about 2 kg of lean tissue sustained over 12 months when compared to patients supplemental during daytime hours (24). Energy and protein intake increased similarly in both treatment groups thus it is hypothesized that by limiting the overnight fasting period with a late-evening “meal” the progression to early onset of nocturnal gluconeogenesis from amino acids is blunted with improvement in net nitrogen balance.

Perioperative nutritional support with 14 days of parenteral nutrition in addition to oral diet has been reported to reduce complications after major hepatectomy for hepatocellular carcinoma associated with cirrhosis compared to patients receiving oral diet alone (25).

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Assessment & Criteria of the Underweight/Sarcopenic Patient

1. Obtain current height, weight and historical body weight. Patient height needs to be measured by clinic staff (patient report of height is not adequate).

2. Assess patient’s fluid status. Evaluate if the patient has fluid retention from

ascites and/or edema. Check abdominal ultrasound or cross sectional imaging results to verify the presence of ascites if not readily apparent from physical exam. Establish an estimated dry weight for the patient or use the patient’s current weight if no fluid retention is present per physician assessment.

3. Nutrition assessment: calculation of BMI (kg/m2), handgrip strength, midarm

muscle circumference, prealbumin level, ability to walk 100 feet (30 meters) and gait speed for 16 feet (5 meters)

a. If a patient’s BMI is <18.5 kg/m2, they will be considered malnourished.

The surgeon and hepatologist with the transplant selection committee should decide if the patient may be activated for liver transplantation based on their current nutritional status.

b. Patients who have BMI <18 kg/m2 should not be activated for transplant until their nutritional status is improved to the extent that they are not felt to be at significantly greater risk for adverse outcome secondary to undernutrition. The primary modality of nutrition support to be recommended is nocturnal tube feeds.

4. Patients identified as undernourished will need to sign a Nutrition Contract

a. They will have to show intake of recommended number of calories and protein as required by the dietician.

b. The patient will enroll in an exercise program and/or physical therpay c. They require close nutritional follow-up. This is primarily to be done by

the SJMC transplant dietician (both in clinic and between visits by phone or MyChart communication). If an outside dietician is included in patient management, records of these visits should be scanned into EPIC to be included in the medical record.

d. If oral intake is inadequate by dietary recommendations, then patients will be required to initiate tube feeds via NJ tube. Nocturnal tube feeds are preferred based upon report of superior outcomes (24). 24 hour tube feeds may be necessary to attain anabolic status.

e. Tube feeding may need to be continued after transplant if necessary nutritional repletion has not occurred before that time.

f. Surgical J tubes and PEG tubes should be avoided due to the high risk of complications.

g. Parenteral nutrition should only be used if the gut is not functioning h. Lipids are strongly recommended in malnourished patients with portal

hypertension, especially those with hyperbilirubinemia due to the presence of fat malabsorption.

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III. Management Of Fat-Soluble Vitamin Deficiency In Cholestasis and Cirrhosis Cholestatic liver disease includes a spectrum of disorders that produce retention of bile acids and bilirubin (the predominant water soluble constituents in bile) in plasma and microscopic evidence for biliary stasis. Changes in bile acid concentration are associated with fat maldigestion from defective micelle formation. This results in malabsorption of fat soluble vitamins and inefficient absorption of dietary fatty acids (26). Vitamin D consists of 2 bioequivalent forms: D2 (ergocalciferol), obtained from vegetable sources and supplements, and D3 (cholecalciferol), obtained from skin exposure to UVB, oily fish, certain fortified foods, and supplements. Once absorbed, both are metabolized in the liver to 25-hydroxyvitamin D (calcidiol) which is subsequently converted to 1,25-dihydroxyvitamin D (calcitriol), primarily in the kidney (27, 28). Vitamin D deficiency is extremely common in patients with chronic liver disease, many of whom have severe deficiency (<7ng/ml) (29, 30). In mild to moderate liver dysfunction, vitamin D malabsorption is the primary contributor to vitamin D deficiency. In severe liver dysfunction, the liver is unable to produce 25-hydroxyvitamin D. 1. Monitoring Fat-Soluble Vitamins:

25-OH Vitamin D level (normal range > 30 mg/ml, 75 nmol/l){some data points to ideal levels from 50 to 70) (If renal disease, check 1,25-(OH)2 Vitamin D) Vitamin A deficiency: diagnosed by clinical manifestation (xeroophthalmia) or laboratory measure. Retinol level <20 mcg/dL or ratio of retinol:RBP <0.8 Serum carotene levels are also correlated with vitamin A and may be used as a surrogate marker of malabsorption and malnutrition Vitamin E level should be performed with concomitant fasting total lipid profile: Effective serum vitamin E level = alpha-tocopherol ÷ (total cholesterol + triglycerides) Ratio > 0.8 is normal; if < 0.6, supplement Vitamin K: measure INR

2. Replacement of Fat Soluble Vitamins:

1. Vitamin D Deficiency

Vitamin D3 (cholecalciferol) is available in 400, 1,000, 5,000, and 50,000 unit capsules., best dose for liver disease patients is 2000 units per day

Vitamin D2 (ergocalciferol) is available in 400 or 50,000 unit capsules and in a liquid form (8,000 units/ml). Typical dose is 50 000 per week.

Some studies suggest that D3 is more efficient in repletion of vitamin D levels.

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Patients who are deficient should be treated with 50,000 IU of vitamin D2 or D3 weekly for 8 weeks followed by 50,000 IU every 2 to 4 weeks or 800-1000 IU daily thereafter. 25-hydroxyvitamin D levels should be monitored approximately 12 weeks after initiation of therapy to assess for efficacy. Patients with significant malabsorption may require higher doses of therapy (as much as 50,000 IU daily or QOD until replete).

If a patient with severe malabsorption is unresponsive to a high dose therapy or if there is co-existent renal failure (eGFR <30 mls/min), the patient should be switched to the oral form of calcitriol (1,25-digydroxyvitamin D, Rocaltrol). Patients with severe liver failure and thus decreased capacity to produce 25-hydroxyvitamin D from vitamin D2 or D3 may also be placed on calcitriol so as to eliminate requirement for this conversion. Calcitriol is available in 0.25 and 0.50 microgram capsules. If this is poorly absorbed, then intravenous calcitriol may be administered.

The initial signs of vitamin D toxicity are hypercalciuria and hypercalcemia. Vitamin D levels need to be followed monthly. Target blood levels of Vit D3 are 40-50.

2. Vitamin A Deficiency

Most patients with chronic liver disease obtain adequate vitamin A from a multivitamin (RDA for adult males in 3000 IU and for adult females in 2300 IU). Patients with cholestasis and deficiency may require 5,000-25,000 daily IU. Patients on high dose supplements require monitoring for toxicity. Blood levels should be checked every 6 months while on high dose therapy.

3. Vitamin E Deficiency:

Vitamin E deficiency is rare and may be manifest as neuromuscular disorders or hemolysis. Serum measurements of vitamin E are unreliable and so accurate levels require concomitant measurement of fasting lipids. In individuals with fat malabsorption, 200 IU daily is usually sufficient to replace vitamin E in healthy people. Up to 800 units per day may be used in CLD patients.

4. Vitamin K Deficiency:

Dietary vitamin K1 (phyloquinones) is found in green leafy vegetables (spinach, kale, broccoli) while normal gut flora may synthesize vitamin K2 (menaquinone). Vitamin K has a major role in the coagulation pathway and is also a cofactor for bone mineralization. Risk factors for deficiency include poor dietary intake, cholestasis with malabsorption, and chronic antibiotic use. Daily requirements are 90mcg for women and 120mcg for men. Oral Vit K appears to have little or no effect on INR levels due to lack of absorption combined with low efficiency of Vit K activation. If increased INR, attempt repletion with Vitamin K 10 mg SQ daily, for three days. Parenteral vitamin K may be given monthly for maintenance, if required. This would

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be most commonly done in patients with primary cholestatic liver disease (PBC or PSC).

ADEK & AQUA ADEK

ADEK tablets and AQUA ADEK capsules are a convenient means of multi fat soluble vitamin repletion, in a water miscible (micellar, more absorbable) formulation, using single pills. Practically, one AQUA ADEK pill would appear roughly equivalent to 2-3 ADEK pills. Choose based upon severity of deficiency.

ADEK AQUA ADEK capsules Vitamin K 150 mcg 700 mcg Vitamin A 5000 IU 18 000 IU Vitamin E 50 IU 150 IU Vitamin D 400 IU 800 IU Information for SJMC Pharmacy supplement cost:

Inpatient cost: ADEK chewable tablet = 26 cents/each Oupatient cost: AquADEKs bottle of 60 capsules = $24.95

Other signs of micronutrient deificncy Dermatitis (zinc, vitamin A, niacin) Night blindness or photophobia (vitamin A) Burning of mouth or tongue (B12 or folate) Easy bruising (vitamin C or K) Paresthesias (thiamine, pyridoxine) Angular stomatitis (Vitamin B12, Vitamin B2, Vitamin B6) Seborrheic dermatitis (Vitamin B2, Vitamin B6, Niacin) Erythema or hyperpigmentation (niacin)

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Figure 1 demonstrating inferior survival following liver transplant in patients with BMI < 18.5 or ≥ 40 compared to those with pre-transplant BMI between 18.5 and < 40 (3).

Compared with the control group, the underweight patients had a higher retransplantation rate due to graft failure and were more likely to die from hemorrhagic complications or cerebrovascular accidents. Analysis of Variables as Predictors of Risk to Survival During Period 3 (March 2002 to 2007; n=27,709 Patients). Shown are results of multivariable analysis

Variable RR P Rank Order Cryptogenic Cirrhosis 3.71 <0.0001 1

Retransplant 1.76 <0.0001 2

Tumor 1.74 <0.0001 3

BMI < 18.5 1.73 <0.0001 4

Hepatitis C 1.52 <0.0001 5

On life support at time of transplant 1.44 <0.0001 6

BMI ≥ 40 1.41 0.0005 7

DCD Donor 1.36 <0.0001 8

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