CASE STUDY: ESLD WITH DIPS

Melanie Boney

Patient 61 year old man with multiple chronic

diseases Anthropometrics

Height 75” / 190.5 cm

BMI: 34.75

Pounds KilogramsAdmit Body Weight 277.6 126.2Usual Body Weight 300 136.4Ideal Body Weight 184 83.6

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 History2/5/2010 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 Large Paracentesis from 1/15 – 3/22 4.5 – 10 L removed

Hepatohydrothorax Repeat Therapeutic Thoracentesis 2/21 – 3

/18 1.5 – 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 edemaStage 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 / day ↑ 10g q3-5 days UL of 0.8-1.0 g/kg

Severe Protein Restriction 0-40g / 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 High protein snacks 1.0 – 1.5 g/kg/day

Poor Dietary Intake Poor appetite/early satiety due to ascites

Small frequent meals Sodium restriction

Abnormal Glucose Metabolism 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 ligation, or banding DIPS / 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

Fig. 1 Transfemoral placement of IVUS probe and puncture of portal vein with modified Rosch-Uchida Portal Access set which has been placed into IVC from a transjugular route.

DIPS

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: 2/8/10Albumin 2.6Prealbumin 11.3Potassium 4.7 Sodium 136Chloride 98Phosphorous 4.4Magnesium 2.0Calcium 8.0CBG’s 213-308Hemoglobin A1C 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: 2/22/10Albumin 2.4Potassium 3.9 Sodium 132Chloride 93Phosphorous 4.4Magnesium 1.7CBG’s 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 discussed his strategies for weight loss Wt. 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-9FD2-A07AC6426961&GDL_Disease_ID=C8BD9205-E51B-4186-B4E4-B5087B21F9EA

Khanna S, Gopalan S. Role of Branched-chain Amino Acids in Liver Disease: the Evidence For and Against. Current Opinion 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. 2006;52:2177-2179.

McClave SA, Martindale RG, Vanek WV, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN. 2009; 33:277-316. doi:10.1177/0148607109335234

Plauth M, Cabre E, Riggio O, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr.2006; 25:285 -294.

Córdoba J, López-Hellın J, Planas M, Sabın P, Sanpedro F, Castro F, et al.  Normal Protein Diet for Episodic Hepatic Encephalopathy: Results of a Randomized Study. J Hepatol. 2004;41:38–43.

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

Stent-Graft. Radiology. 2008;246:306-314. Rose JDG, Pimpalwar S, Jackson RW. A New Stent-graft for Transjugular Intrahepatic Portosystemic Shunts. British

Journal of Radiology. 2001;74:908-912.