Nutrition Care for Diabetes after Liver Transplant

Angela Matthewson, RD LD CNSD

Instructor in Nutrition, Mayo Clinic

Jacksonville Dietetics Association

September 18, 2009

Objectives

• Recognize incidence, risk factors, and consequences of post-transplant diabetes mellitus (PTDM) among liver recipients

• Identify short-term and long-term complications related to PTDM

• Understand role of registered dietitian (RD) in management of PTDM

• Describe use of Stages of Change in the management of PTDM

Liver Transplant

• 5 year survival after Orthotopic Liver Transplant (OLT)

• 70-80%• Good Quality of Life

• New Challenge … long-term management• Cardiovascular disease: among most serious

conditions to develop after transplant• Diabetes: leading risk factor for CVD

Benten 2009

Immunosuppressant Side Effects

• Major cause long-term mortality & morbidity after OLT

• >1/2 deaths after 3 year survival:• Atherosclerotic cardiovascular disease

(ASCVD)• Correct or control potentially reversible CV risk

factors (i.e. DM, dyslipidemia, obesity, hypertension)

• De novo malignancies• Regular surveillance

Benten 2009, Reuben 2001

Drug Effects

Benten

Adverse effect Ciclo-sporin

Tacro-limus

Gluco-corticoids

Azathioprine Myco-phenolate mofetil

mTOR inhibitors

Arterial HTN +++ ++ +++ - - +

Hyperglycemia, DM

- (?) + +++ - - -

Hyperlipidemia ++ + ++ - - +++

Nephrotoxicity +++ (K+, Mg2+)

+++ (K+, Mg2+)

- - - + (proteinuria)

DM Etiology

• Tissue resistance to insulin-mediated glucose uptake

• β-cell failure, inability to compensate for insulin resistance

Rizvi

Immunosuppressants & DM Etiology

• Corticosteroids• Increase insulin resistance• Increase hepatic gluconeogenesis• Decrease glucose use in muscle and adipose

tissue

• Calcineurin Inhibitors (CNIs)• Increase insulin resistance• Pancreatic beta-cell toxicity

Rizvi 2004, Marchetti 2005

Hyperglycemia Outcomes

• Short-term consequences• Infections• Graft rejection

• Long-term consequences• Microvascular complications• Progressive HCV disease• Increased risk ASCVD

Rizvi 2004, Swift 2006

DM & Other Side Effects

• DM risk increases with obesity & sedentary lifestyle

• Microvascular complications responsible for most adverse outcomes

• Link between DM2 & CVD major determinant early mortality

• Risk for future CV event: Presence of DM2 = Established CVD

• DM v. no DM: 2 to 4 fold increased risk for MI

Rizvi, Horan

DM & Other Side Effects

• Expanding perception of DM

• Cluster of risks:

• Each impacts at least one other

• Each contributes to overall risk ASCVD

• Immunosuppressants increase risk of each

Rizvi 2004, Horan 2006, Beckman

Immunosuppressant Side Effects

Arterial HTN

Hyperglycemia / DM

Nephrotoxicity

Dyslipidemia

Risk ASCVD

Diet

Obesity/Overweight

PTDM: Diagnosis & Incidence

• American Diabetes Association & World Health Organization diagnostic criteria:

• Fasting plasma glucose ≥126 mg/dL (7 mM)

• OLT recipients pre-transplant• 10-30%

• New-onset diabetes mellitus (NODM) in OLT recipients

• 20-40%• Incidence is cumulative over time

Marchetti 2005, Benten 2009, Ma 2005, Oufroukhi 2008, Steinmüller 2000, Reuben 2001

PTDM: Risk Factors

• HCV

• Immunosuppressant type/dose: CNI, Steroids

• Pre-transplant glycemia

• Alcohol

• Recurrent viral disease

• Family history

• African-American or Hispanic ethnicity

• Male gender

• Age >40 years

• Increased weight

• Metabolic syndrome

Marchetti 2005, Benten 2009, Ma 2005, Oufroukhi 2008, Steinmüller 2000, Reuben 2001

Diabetes Impact

What can we do?

DM: Change Outcomes

• Improved Glycemic control decreased microvascular risk, DM dyslipidemia

• Hemoglobin A1c• DCCT: 1% decrease 60% decrease

microvascular complication• UKPDS (over 10 year follow-up): every 1%

decreases 37% decrease microvascular complications

• 5% weight loss • Increased insulin sensitivity• Decreased fasting blood glucose• Decreased medication needs

Horan 2006, Beckman

DM: Interventions

• Lifestyle modification

• Diabetes Self-management Education (DSME)

• General guidelines:• More Intensive• Clear guiding theory• Face-to-face delivery• Inclusion physical activity• Include cognitive restructuring and

patient/educator interaction• Team management

Rizvi 2004, Skinner 2008

DM: Interventions

• Individual counseling with RD• 1.9% reduction in HbA1c with intensive RD

intervention• Better outcomes than with medication alone

• Patient-tailored• Simplified educations among lower literacy

patients Improved comprehension and compliance

Rizvi 2004, Swift 2006, Bantle 2008 2004, Horan 2006, Wilson

DM: Interventions

• Structured group education • Greater weight loss• Less likely to smoke• Greater changes in illness beliefs• Lower depression

• More facilitative, less didactic education • Greater change in illness beliefs

• Patient empowerment – patients involved in setting realistic goals according to their lifestyles

Davies 2008, Skinner 2008, Horan 2006

DM: Nutrition Care

• No more taboo foods

• Research refutes a specific “diabetic diet”

• Meal planning based on individual preferences better compliance and achievement metabolic goals

Rizvi 2004, Swift 2006, Bantle 2008, Horan 2006

DM: Nutrition Care

• Carbohydrate consistency• 45-65% total calories• Provide energy, fiber, vitamins, minerals• Meals may vary from each other, but daily

amounts at each should be constant• Snacks not required• Unnecessary to eliminate sucrose• No research to support one method versus

another for carbohydrate content estimation

Bantle 2008, Swift 2006

DM: Transtheoretical Model / Stages of Change

• Precontemplation: No intent to change behavior within next 6 months

• Contemplation: Stated intent to change behavior within next 6 months

• Preparation: Intention to take specific steps toward behavior change within the next month

• Action: Overt behavior changes within the past 6 months - not yet well-established

• Maintenance: Behavior changes have lasted greater than 6 months

Vallis 2004

Traditional interventions are action-oriented

Those in pre-action stages do not benefit

DM: Transtheoretical Model / Stages of Change

• Individuals with DM in action phases compared to pre-action stages

• Fewer calories from fat• Lower BMI• More likely DSME in past year• More frequent MD appointments• Less likely to smoke• Fewer psychosocial problems• Older, more females, more insulin users

Vallis 2004

DM: Transtheoretical Model / Stages of Change

• Chicken or egg?

• Controllable:• DSME & medical follow-up frequency• Social interventions to improve QoL &

support

• Non-controllable:• Take factors into account when intervening

Vallis 2004

PTDM: Management

• Immediate post-transplant• In-patient education:

• Motivate to participate in glycemic control• Rationale to limit carbohydrate foods to 3 meals• Carbohydrate foods• Non-carbohydrate snack examples

• Refer as needed for outpatient follow-up after discharge

PTDM: Management

• Commonly Used Insulin Preparations post-OLT

Preparation Action Onset (h)

Peak Action (h)

Effective Action duration (h)

Maximum duration (h)

Insulin aspart

(NovoLog)

¼ - ½ ½ - 1 ¼ 3-4 4-6

Basal Insulin

3-4 8-16 18-20 20-24

PTDM: Management

• Chronic post-transplant• All patients attend 4 month follow-up• RD education• Screen for additional education needs

Chronic Post-transplant

• Content: Mediterranean diet/lifestyle

• Goal: • Reduce risk factors for ASCVD

• Manage long-term immunosuppressant side effects

• Format: interactive

• Stages of change: • Provide motivation for behavior change• Encourage incremental steps

• Patient-centered: • Provide patients with lipid profiles• Instruct to set personal goals

Chronic Post-transplant

• Diabetes Assessment Risk Tool• Diagnosis status, BMI, dyslipidemia,

hypertension, medication/insulin

• Referral as needed to Diabetes Education Program

Case Study 1 - AB

• 61 y.o. female

• OLT 8/3/09 for EtOH

• No DM pre-OLT; required insulin gtt in SICU; transitioned to Novolog sliding scale once transferred to transplant ward

Case Study 1 - AB

• Nutrition Assessment: 8/3/09• Intubated and sedated; no family present.

Therefore, no diet/weight hx obtained.

• Nutrition Follow-up: 8/7/09• Height 158 cm, 52.2 kg, 20.9 BMI• Weight hx: dry weight stable PTA, 12% weight

loss in 2 weeks represents severe fluid fluctuation

• Diet hx: Pt eating 3 meals per day, >75% each• Labs: WBG 112-144 past 24 hrs• Estimated nutrition needs: 1500 kcal (29

kcal/kg), 73 g protein (1.4 g/kg)

Case Study 1 - AB

• Education• Rationale to restrict carbohydrates to meals only

• Sliding scale insulin given at meals and not effective between

• Relationship between glycemic control and wound healing / infection risk / rejection risk

• Food safety principles also reviewed

• Outcome• Verbalized and demonstrated understanding

• Goals• Able to state relationship between diet and lab values• Identify ways to modify current intake• Identify food selection principles

Case Study 1 - AB

• Nutrition Diagnosis: Knowledge deficit related to dietary guidelines for steroid induced diabetes as evidenced by patient reported lack of previous exposure.

Case Study 2 - GD

• 69 y.o. female

• OLT 7/8/09 for cryptogenic cirrhosis

• DM pre-transplant; insulin drip initially post-transplant, transitioned to Novolog sliding scale

Case Study 2 - GD

• Nutrition assessment: 7/10/09• Height: 164 cm, Admit weight: 82 kg,

estimated dry weight: 72.5 kg, BMI 27 (WNL)• Weight history: Fluctuated with fluid, unable

to determine underlying dry weight changes• Diet history: Ate 3 meals, plus 2 snacks and

Ensures at home. Current appetite decreased, but forcing self to eat 3 meals

• Estimated nutrition needs: 1725 kcal (BEE x 1.3), 94 g protein (1.3 g/kg)

Case Study 2 - GD

• Assessment, continued• Education: food safety information reviewed• Intervention: Glucerna with breakfast and

dinner

• Nutrition follow-up: 7/13/09• Current intake: 3 meals but very small

amounts, drinking supplements between• Labs: WBG 152-222

Case Study 2 - GD

• Education• Rationale to restrict carbohydrates to meals only

• Sliding scale insulin given at meals and not effective between

• Relationship between glycemic control and wound healing / infection risk / rejection risk

• Food safety principles also reviewed

• Outcome• Verbalized and demonstrated understanding

• Goals• Able to state relationship between diet and lab

values• Identify ways to modify current intake• Identify food selection principles

Case Study 2 - GD

• Nutrition follow-up 7/16/09• PO somewhat improved. 3 small meals +

supplement with each

• Education• Reviewed prior topics• Patient and spouse without questions

• Outcome• Verbalization of understanding• State who to call if questions

Case Study 2 - GD

• Nutrition Diagnosis: Knowledge deficit related to dietary guidelines for steroid exacerbated diabetes as evidenced by consumption of carbohydrates between meals.

Conclusions

• PTDM is common and serious complication post-OLT

• Proper management abates negative sequelae

• Interventions should include multidisciplinary team with consistent message

• RD provides nutrition component

• Goals, format tailored to patient

References• Bantle JP, et al. Nutrition recommendations and interventions for diabetes:

a position statement of the American Diabetes Association. Diabetes Care 2008; 31(S1): S61-S78.

• Benten D, et al. Orthotopic liver transplantation and what to do during follow-up: recommendations for the practitioner. Nature Clinical Practice: Gastroenterology and Hepatology 2009; 6(1): 23-36.

• Davies MJ, et al. Effectiveness of Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. British Medical Journal 2008; 336: 491-495.

• Endotext. http://www.endotext.org/diabetes/diabetes20/ch01s06.html. Accessed September 6, 2009.

• Horan KL, et al. An overview of nutrition and diabetes management. Topics in Clinical Nutrition 2006; 21(4):328-340.

• Ma Y, Yan W. Chronic hepatitis C virus infection and post-liver transplantation diabetes mellitus. World Journal of Gastroenterology 2005; 11(39): 6085-6089.

• Marchetti P. New-onset diabetes after liver transplantation: from pathogenesis to management. Liver Transplantation 2005;11(6): 612-620.

References

• Oufrouki L, et al. Predictive factors for posttransplant diabetes mellitus within one-year of liver transplantation. Transplantaion 2008;85: 1436-1442.

• Reuben A. Long-term management of the liver transplant patient: diabetes, hyperlipidemia, and obesity. Liver Transplantation 2001; 7(11): S13-S21.

• Rizvi AA. Type 2 diabetes: epidemiologic trends, evolving pathogenic concepts, and recent changes in therapeutic approach. Southern Medical Journal 2004; 97(11): 1079-1087.

• Skinner TC, et al. ‘Educator talk’ and patient change. Diabetic Medicine 2008; 25: 1117-1120.

• Steinmüller TH. Liver transplantation and diabetes mellitus. Experimental and Clinical endocrinology and Diabetes 2000; 108(6): 401-405.

• Swift CS, Boucher JL. Nutrition therapy for the hospitalized patient with diabetes. Endocrine Practice 2006; 12(S3): 61-67.

• Vallis 2004 M, et al. Stages of change for healthy eating in diabetes. Diabetes Care 2003; 26(5): 1468-1474.

• Wilson C, et al. Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian Health Service. Diabetes Care 2003; 29(9): 2500-2504