【導(dǎo)讀】HepatitisC. Gluconeogenesis. Glycogenolysis. Ketogenesis. Fatstorage. Reversible. Simplesteatosis. Steatohepatitis(NASH). Cirrhosis. Overweight. Obesity. CentralObesity. Lifestyle:. Weightgain. Weightloss. Reducedactivity. Type2diabetes

　　

【正文】 Does the timing or frequency of meals of meals matter? Nutritional Management of End Stage Liver Disease ? Reduced glycogen storage capacity Nutritional Management of End Stage Liver Disease Eating Pattern ? Swart and Zillikens demonstrated that spreading food intake and inclusion of a late evening meal significantly improved nitrogen balance in cirrhotics* *Swart G, Zillikens M. Effect of a late evening meal on nitrogen balance in patients with cirrhosis of the liver Med J 1989。299: 12023 Nutritional Management of End Stage Liver Disease Eating Pattern ? A modified eating pattern should be remended to all patients with ESLD. ? This would include eating at regular intervals – perhaps 57 small HP/HE meals/snacks per day ? Include a prebedtime HP/HE snack to provide substrate for the liver to work with during sleep (supplements) Ascites ? Patients with ascites usually have a high total body sodium but often have a low se sodium ? Generally have a poor intake secondary to abdominal distension ? Early Satiety ? Delayed gastric emptying ? Frequent snacking important to achieve high energy intake Ascites ? Sodium restricted diet. Most mon restriction is a no added salt diet which can range between 50Mm Na and 100Mm Na ? Diuretics. Most monly used are Lasix and Aldactone. ? Salt substitutes contraindicated due to potassium sparing effect of aldactone Ascites ? Fluid restriction ? Moderate (1500ml )to severe (≤ 800ml) ? ≤800ml used to treat intractable ascites unresponsive to diuretic therapy or when diuretic therapy no longer possible due to promised renal function ? Don’t measure: custards, ice cream Oesophageal Varices ? Varices can occur at any point along the GIT ? Oesophageal varices may bleed easily and bleeding further promises the patient39。s nutritional status Oesophageal Varices ? Varices can occur at any point along the GIT ? Oesophageal varices may bleed easily and bleeding further promises the patient39。s nutritional status Oesophageal Varices ? Following an oesophageal bleed the patient will be nil by mouth ? Varices will be banded ? Oral intake remenced when patient’s condition stabilises Oesophageal Varices When allowed to eat patients should be advise to: ? Eat carefully and avoid large bolus of food which might dislodge a clot ? Avoid over distension of the stomach which might lead to regurgitation or vomiting ? Avoid foods with sharp bones that might be accidentally swallowed Diabetes in Liver Disease Patients with ESLD may present with impaired glucose tolerance. This may be due to a number of factors: ? Depleted hepatic glycogen stores ? Impaired glucose tolerance ? Hyperinsulinaemia ? Insulin resistance Diabetes in Liver Disease ? Management involves diabetic education without restriction of energy intake ? Insulin therapy ? BCAA supplementation has been shown to facilitate control of blood sugar levels in patients with ESLD Nutritional Management of End Stage Liver Disease ? Achieve and maintain high energy intake(3540 non protein kcal/kg/day) ? Achieve and maintain a high protein intake() ? Avoid unnecessary fat restriction ? Encourage frequent snacking Nutritional Management of End Stage Liver Disease ? Restrict dietary sodium intake in the presence of ascites and/or oedema ? Restrict fluid intake to assist in the management of ascites/oedema associated with hyponatraemia Nutritional Management of End Stage Liver Disease ? Consider branched chain amino acid supplementation ? Significant prebedtime snack Nutritional Response to Hepatic Transplantation Hepatotoxicity of Herbal Remedies ? Herbs are potent medicines ? The munity is increasingly seeking out alternative or “natural” therapies ? Patients with hepatitis C frequently seek out alternative therapies Hepatotoxicity of Herbal Remedies ? Important to be aware of the possible harmful effects of herbs ? Some herbs are hepatotoxic and patients with known liver disease should avoid using them Nutritional Management of NAFLD Treatment centres around reducing insulin resistance ? Dietary intervention ? Increased physical activity ? Metformin Nutritional Management of NAFLD ? Weight loss strategies in presence of overweight/obesity. Weight loss results in improved lipid and carbohydrate metabolism. ? Weight loss must be slow. Rapid weight loss results in worsening liver function tests and hepatomegaly ? Rapid weight loss may promote or worsen NAFLD, NASH and may result in liver failure Nutritional Management of NAFLD ? Normal weight subjects: dietary and pharmacological treatment of altered lipid and /or carbohydrate metabolism ? In overweight individuals with elevated aminotransferase levels weight loss of 10% or more corrects aminotransferase levels and decreases hepatomegaly Nutritional Management of NAFLD Modification in lifestyle which involves weight reduction and regular exercise are the mainstay of treatment and prevention of NAFLD Nutritional Management of NAFLD Summary There is no quick fix and there are no gimmicks for the consumer –Weight control –Increased exercise/physical activity –Good Diabetic control –Manage lipid abnormalities