MNT 2 Exam III

What are the main functions of the liver?

The liver plays a crucial role in metabolism, detoxification, and the production of bile. It also stores vitamins and minerals, regulates blood sugar levels, and synthesizes proteins essential for blood clotting.

Total Bilirubin

Increased because normal liver makes bile and bilirubin is excreted with bile

Prothrombin Time

a measure of how long it takes blood to clot, indicating liver function and vitamin K levels.

Alanine Amino Transferase (ALT)

An enzyme found primarily in the liver that helps convert alanine and alpha-ketoglutarate to pyruvate and glutamate, serving as a marker for liver function.

Aspartate Amino Transferase (AST)

An enzyme found in the liver and heart that helps convert aspartate and alpha-ketoglutarate to oxaloacetate and glutamate, also used to assess liver function.

Alkaline Phosphatase (ALP)

An enzyme associated with the bile ducts, liver, and bones, elevated levels can indicate liver disease, bile duct obstruction, or bone disorders.

Lactate Dehydrogenase (LD/LDH)

An enzyme that catalyzes the conversion of lactate to pyruvate in the presence of NAD, involved in energy production and often measured to assess tissue damage.

Ammonia

Increased because diseased liver does not produce urea adequately

Albumin, prealbumin, and transferrin are expected to be ___ in liver dz.

Low

Major function of the gallbladder?

To store, concentrate, and secrete bile produced by the liver for digestion.

What are the main functions of the pancreas?

Endocrine: produces insulin and glucagon;

Exocrine: produces digestive enzymes and bicarbonate.

Jaundice

Yellowish tint in body tissues caused by large quantities of bilirubin in extracellular fluid

Ascites

Accumulation of fluid in the abdominal cavity, often due to liver disease or heart failure.

What is the treatment for ascites?

Treatment may include sodium restriction, diuretics, paracentesis, and addressing the underlying cause, such as liver disease.

Paracentesis

A medical procedure that involves inserting a needle into the abdominal cavity to remove excess fluid.

Why would we need dry BW when adjusting for ascites?

To accurately assess hydration status and fluid shifts.

What are some of the ways to adjust for ascites?

Subtracting these from their current BW:

Mild: 3-5 kg

Moderate: 7-9 kg

Severe: 14-15 kg

Pt. reported UBW

BW after paracentesis

1 kg/L fluid removed

IBW

Encephalopathy

A decline in brain function, often due to metabolic disturbances or liver failure, leading to confusion and altered mental state.

What causes Wernicke’s encephalopathy?

is a deficiency in thiamine (vitamin B1), often associated with alcoholism, malnutrition, or prolonged vomiting.

Hepatic Encephalopathy

A neurological disorder caused by liver dysfunction, leading to the accumulation of toxins in the brain, resulting in confusion, altered consciousness, and even coma.

What are some of the symptoms of encephalopathy?

Symptoms can include confusion, altered mental status, hand tremors (asterixis). memory problems, personality changes, and in severe cases, seizures or coma.

What is the nutrition treatment for encephalopathy?

Reducing circulating ammonia, so 1.2-1.5 g protein/kg of dry weight

• Assists in preventing catabolism

Adequate calories 25-30 kcal/kg

Plant proteins may be better tolerated

Zinc supp if deficienct

BCAA emphasized formulas can help with symptoms

What are the 4 types of hepatitis?

Hepatitis A, B, C, D/E

Acute Hepatitis A

Caused by the Hepatitis A virus, leading to sudden onset of symptoms such as jaundice, fatigue, nausea, and abdominal pain. It is usually transmitted through contaminated food or water. Transmitted almost exclusively by the oral-fecal route.

Serum Hepatitis or Hepatitis B

Caused by the Hepatitis B virus, resulting in both acute and chronic liver disease. Transmission occurs primarily through blood and bodily fluids. Complications include cirrhosis and hepatocellular malignancy.

Hepatitis C

A viral infection that affects the liver, often leading to chronic disease and potential liver damage over time. It is primarily transmitted through exposure to blood or body fluids from an infected person. Associated with development of chronic liver disease, cirrhosis, and need for liver transplant.

Hepatitis D and E

Uncommon, requires Hep B to replicate, acute infection, rare in the U.S.

What are common symptoms of hepatitis?

Anorexia, N/V, joint pain, jaundice

Acute: Abdominal pain, n/v, loss of energy, elevated liver enzymes

Chronic: Fatigue, jaundice, abdominal discomfort

What is the difference between anorexia and anorexia nervosa?

Anorexia refers to a loss of appetite or desire to eat due to illness, while anorexia nervosa is a serious mental health disorder characterized by extreme weight loss, distorted body image, and an intense fear of gaining weight.

What is the nutrition intervention for viral hepatitis?

Kcals to maintain/regain weight (25-35 kcal/kg dry weight), protein 1-1.2 g/kg, adequate fluid, avoid alcohol

With chronic hep, lifelong avoidance of alcohol

Alcoholic Liver Disease

A condition caused by excessive alcohol consumption leading to liver inflammation, fatty liver, cirrhosis, and potentially liver failure.

One of the most significant health problems in the U.S.

Defined as >4 drinks/day men, >2 drinks/day women

What are the three disorders included in alcoholic liver disease?

Fatty liver (hepatic steatosis), alcoholic hepatitis, cirrhosis

Fatty liver (hepatic steatosis)

is the accumulation of fat in liver cells, often associated with excessive alcohol consumption and can lead to further liver complications.

Can be in alcoholics and non-alcoholics

Nonalcoholic fatty liver disease

• Linked with metabolic syndrome, obesity, and high fat diets

• Usually asymptomatic

Alcoholic hepatitis

is a serious inflammation of the liver caused by excessive alcohol intake, characterized by symptoms such as nausea, malaise, low-grade fever, fatigue, weakness, anorexia, fever, hepatomegaly

Chronic can progress to cirrhosis

Cirrhosis

is a late-stage liver disease characterized by the replacement of healthy liver tissue with scar tissue, commonly resulting from chronic alcohol abuse or other liver disorders.

Common causes are Chronic Hep C and alcoholism

Therapeutic intervention, primarily nutritional treatment, can alleviate major complications of cirrhosis

What are the nutrition consequences for alcoholic liver disease?

Metabolic competition for nutrients

malnutrition, sarcopenia, and vitamin deficiencies are common comorbidities

What are the nutrition interventions for NAFLD?

Nutrition therapy to promote weight loss, vitamin E, Mediterranean diet, and omega-3

What is the nutrition intervention for ALD?

Avoid alcohol consumption, correct nutritional deficiencies (thiamin, folic acid common),

kcals 25-35 kcal/kg dry weight

protein 1-1.2 g/kg

• Late stages or malnourished 1.2-1.5 g/kg dry weight

Monitor dry weight changes

What are the clinical manifestations of cirrhosis?

General

• Fatigue, weakness, nausea, poor appetite, and malaise

Liver-specific symptoms

• Jaundice, dark urine, steatorrhea, abdominal pain, and bloating

Vitamin and mineral deficiencies are common

Portal hypertension, hepatic encephalopathy, ascites, and esophageal varices

Portal Hypertension

Increased blood pressure in the portal venous system, often due to liver cirrhosis, causing complications such as ascites and varices.

Esophageal Varices

Swollen veins in the esophagus that develop due to increased pressure in the portal vein, often resulting from liver cirrhosis. They can lead to serious bleeding and require medical management.

What is the treatment for cirrhosis?

Abstain from alcohol

Diuretics for ascites

Lactulose to trap ammonia

What are some of the nutritional considerations for someone with cirrhosis?

Early satiety from ascites

• Puts pressure on stomach

• Concurrent muscle wasting

impaired nutrient digestion and absorption

• Especially fat

erratic blood sugar

• Affects pancreatic fxn

  • Poor glycogen stores, enter “fasting” faster

What is the nutrition intervention for cirrhosis?

35-40 kcal/kg or 1.2-1.4 x REE

Protein should not be restricted 1.2-1.5 g/kg

Carbohydrate restrictions (moderation) in patients with diabetes

Sodium restriction in ascites, fluid too, aqua ADEK

Enteral feeding in patients that have inadequate oral intake

Soft diet for patients with esophageal varices

Liver Transplant

A surgical procedure to replace a diseased liver with a healthy one from a donor, indicated for end-stage liver disease such as cirrhosis, or also chronic active hepatitis.

What is the nutrition therapy for liver transplant?

35-40 kcal/kg and 1.2-1.5 g/kg protein

Oral nutrition is preferred

During adaptation time, aqua ADEK

Food safety, manage malnutrition and ascites, need for early nutritional support after surgery

Monitor anthros, dietary intake, and GI symptoms, as well as fluid retention

Monitor biochemical lab values

Assess side effects of post-transplant medications

Cholelithiasis (Gallstones)

Presence of solid particles that form in the gallbladder, often causing pain or discomfort, and can lead to complications.

Form from cholesterol

Increased risk in those with obesity, diabetes, IBD, or bariatric surgery

Cholecystectomy likely needed

What are some complications from gallstones?

Complications from gallstones include acute cholecystitis and bile duct obstruction. They may lead to severe pain, infection, or require surgical intervention.

Affects fat digestion and absorption, so no bile flow into

What is the the nutrition therapy for cholelithiasis?

Prevention:

• Moderate caffeine intake

• Moderate fat intake

• Increased fiber intake (F&V)

Before Surgery:

• Low-fat diet with modest protein, <30% fat

• Small frequent meals

• Aqua ADEK if necessary

• If having acute attack, NPO

After Surgery

• Diarrhea managed through increased fiber intake

• Fats introduced gradually

  • Adjusting to changes in bile

Acute Pancreatitis (AP)

Infection and inflammation of the pancreas, often originating from gallstones, high fat intake, or excessive alcohol use.

What are the symptoms of acute pancreatitis?

Upper abdominal pain radiating to the back, worsening with ingestion of food

What is the treatment for acute pancreatitis?

Intravenous fluids and analgesics

Severe AP requires intensive care

What is the nutrition therapy for acute pancreatitis?

Mild AP: Oral feeding, low-fat food choices typically tolerate, some low oral, some NPO

Severe AP: Early EN is recommended, jejunal if necessary

Increased kcal and protein needs for both

• 25-30 kcal/kg

• 1.2-1.5 g/kg protein

Chronic Pancreatitis

A long-term inflammatory condition of the pancreas that leads to irreversible damage, resulting in chronic abdominal pain, malabsorption, and diabetes.

What is the etiology for chronic pancreatitis?

Alcoholism, smoking, previous diagnosis of AP, potench genetics

What is the nutrition therapy for chronic pancreatitis?

Depends on underlying etiology and level of endocrine and exocrine

Usually leads to malabsorption of all macronutrients and some micronutrients

Decreased oral intake with pain

Goals: prevent further injury, alleviate pain, correct steatorrhea, prevent weight loss

High caloric intake: up to 35 kcal/kg/day

Protein: 1.2-1.5 g/kg/day

Pancreatic enzymes at each meal/snack

Supplementation of vits./mins. (ADEK)

MCT oil if steatorrhea

Monitor for gastroparesis

Monitor glucose control

Why would pancreatic surgery be requried?

Pancreatic surgery may be required to relieve pain, remove obstructions, or treat complications such as pseudocysts or cancer. It can also help restore normal function when other treatments fail.

What is a pancreaticduodenectomy?

A surgical procedure that removes the pancreas head and part of the duodenum, typically performed to treat pancreatic cancer or severe pancreatitis.

What are the main differences between AP and CP?

Acute pancreatitis (AP) is a sudden inflammation of the pancreas, often caused by gallstones or alcohol, while chronic pancreatitis (CP) is a long-term inflammation that leads to permanent damage, usually due to prolonged alcohol abuse or familial factors.

What is whipple?

The Whipple procedure, or pancreaticoduodenectomy, is a complex surgery involving the removal of the head of the pancreas, the duodenum, part of the bile duct, and often the gallbladder, primarily performed to treat pancreatic cancer.

What are the needs for someone after pancreatic surgery?

Postoperative care may include pain management, monitoring for complications like infection or bleeding, nutritional support, and follow-up assessments to ensure proper healing.

High-calorie, high-protein

Pancreatic enzymes prescribed for each meal and snack

Vit./min. status assessed periodically so supplementation can prevent and treat any deficiencies

What are the primary causes of kidney disease?

Common causes of kidney disease include diabetes, obesity, high blood pressure, glomerulonephritis, and polycystic kidney disease, along with certain infections and drug toxicity.

What are some of the main complications of kidney disease?

Azotemia, renal osteodystrophy, and secondary hyperparathryoridism

Azoetemia

is a condition characterized by an accumulation of nitrogenous waste products, such as urea and creatinine, in the blood, often indicating impaired kidney function.

Renal osteodystrophy

A bone disorder that occurs due to imbalances in calcium, phosphorus, and vitamin D as a result of chronic kidney disease.

Secondary hyperparathyroidism

is a disorder characterized by elevated parathyroid hormone levels due to impaired kidney function, leading to disturbances in calcium and phosphate metabolism.

How do calcium and vitamin D affect parathyroid hormone?

Calcium and vitamin D help regulate parathyroid hormone levels; low calcium or vitamin D deficiency can lead to increased parathyroid hormone production.

What are signs/symptoms associated with kidney disease?

Hypertension, edema, anemia, azotemia/uremia, hyperkalemia, secondary hyperthyroidism, renal osteodystrophy

Nephrolithiasis

is a condition characterized by the formation of kidney stones, which are hard deposits made of minerals and salts that form inside the kidneys.

What are the risk factors for nepholithiasis?

Family history, hypercalcemia, hyperoxaluria, low urine volume, malabsorption

Other causes: Gout, excess intake of vit. D, UTIs

Hyperoxaluria

excessive oxalate in the urine due to dietary or metabolic abnormalities.

What is the main diagnosis for nephrolithiasis?

Patients pass stones with plenty of fluid and pain meds., extracorporeal shock wave lithotripsy is the most common if too large

What is the main nutrition therapy for nephrolithiasis?

Increase fluid intake by 2-3 L/day

No need to avoid dietary calcium

Control oxalate intake and excretion

• Ca foods with meals

• Limit nuts, bran, chocolate, beans

Best way to control is by knowing stone composition

Gout

a type of arthritis characterized by sudden, severe attacks of pain, redness, and swelling in the joints, caused by the accumulation of uric acid crystals.

What are the signs/symptoms of gout?

Common signs include intense joint pain, swelling, redness, and stiffness, often starting at the big toe.

What are the risk factors for gout?

More common in men, genetics, common comorbidity with obesity

What is the prevention/management for gout?

Low purine diet + meds that decrease uric acid

What foods should be avoided in a low purine diet?

Red meat, alcohol (especially beer), shellfish, organ meats, high purine veggies: mushrooms, spinach, cauliflower, asparagus

Acute Kidney Injury (AKI) (AKA Acute Renal Failure [ARF])

Abrupt cessation or decline in GFR that results in failure to maintain fluid, electrolyte, and acid-base balance

What is the epidemiology for AKI?

Affects hospitalized patients

Usually doesn’t exist alone, happens alongside other conditions

Poor prognosis and high mortality rate

What are the clinical manifestations of AKI?

Serum levels of potassium, mag, and phosphorus generally elevated

BUN and creatinine elevated

Decreased urine output

What is the nutrition therapy for acute kidney injury?

Depends on type of dialysis

Enteral feeding early if possible

Up to 30-40 kcal/kg

• EN: 20-30 kcal/kg or REE x 1.3

Protein: 0.8-2.5 g/kg

Fluid balance and mineral balance need to be carefully monitored

Chronic Kidney Disease (CKD)

Irreversible progressive loss of kidney function

What are the five stages of CKD?

The five stages of Chronic Kidney Disease range from Stage 1, which is mild kidney damage with normal or high GFR, to Stage 5, which is kidney failure requiring dialysis or transplantation.

What is the treatment for early stage CKD?

May only require an EPO replacement and vit. D supp.

What is the treatment for stage 5 CKD?

Hemodialysis, peritoneal dialysis, and kidney transplantation

Dialysis

AKA Renal Replacement Therapy

• Removal of excessive and toxic by-products of metabolism from the blood replacing function of kidney

What does ESRD stand for?

End-stage renal disease

Hemodialysis

Most common

Filtration achieved outside the body

Typical regimen is 3 times a week for an avg. 4 hours per treatment

Peritoneal Dialysis (PD)

May be done w or w/o machine

Catheter inserted into peritoneal cavity

Uses dextrose concentrations to create osmotic gradient

• Has calories and glucose

Most common in children

What does CRRT stand for?

Continuous renal replacement therapy

CRRT

Reserved for critically ill patients in ICU and AKI usually

Machine causes increased protein losses

Removes fluids and solutes slowly and continuously

Doesn’t remove high amounts of fluid

Why is malnutrition common in CKD?

Malnutrition is common in chronic kidney disease (CKD) due to factors such as dietary restrictions, loss of appetite, inflammation, and increased nutrient requirements related to kidney function decline.

What are the factors leading to malnutrition in CKD?

Inadequate food intake due to social barriers (limited income, inability to prepare foods and meals, living and eating alone, depression, missed meals due to travel and/or treatments)

Increased energy expenditure and protein loss, related to: protein catabolism, inflammation, dialysis

What is the nutrition intervention for CKD stages 1-4?

Managing comorbidities (diabetes, hypertension, hyperlipidemia)

• Control sodium intake (2-2.3 g/day)

• Normalize blood lipids, BG

Delay progression of CVD and CKD

Low-protein diet (but adequate) (0.6-0.8 g/kg)

Adequate kcal to prevent malnutrition

Vit. D, potassium, phosphorus (800-1000 mg/d), calcium, iron

What is the nutrition intervention for stage 5 CKD?

Protein needs:

• On HD: at least 1.2 g/kg

• On PD: at least 1.2 g/kg

• Patients on CRRT require > 2.5 g/kg

Energy needs - HD and PD: 3-035 kcal/kg/day

• Glucose/calories from dialysate should be taken into account

• CRRT needs same, or based on comorbidities

Nutrients to monitor

• Fiber - 20-30 g/day

• Fat - 20-30% total kcals

What is the rules for CKD stage 5 and potassium?

On HD:

• 2-3 g/day restriciton

  • 40 mg/kg/d

• Nutrition education on limiting high potassium foods

  • Bananas, potatoes, avocado, dried fruits, beans, nuts/seeds, salt substitutes

On PD and CRRT:

• Most don’t need restriction

What are the rules for fluid and sodium on CKD stage 5?

Fluid and sodium are controlled

• Fluid individualized and based on urine output

  • HD: 1-3 g/day Na

  • PD: 2 g/day Na

  • CRRT: Na as tolerated

What are the rules for phosphorus on CKD stage 5?

HD and PD: Dietary phosphorus restriction of 800-1000 mg/day

• Most patients use phosphate binders

• High phos foods to avoid: dairy, organ meats, chicken, nuts

CRRT: Unrestricted

What are the rules for calcium in CKD stage 5?

Remember correct Ca equation since low serum calcium may look low

Limit to 2000 mg/day from all sources