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listlengths 384
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Alpha\n1\n-antitrypsin\tis\ta\nglycoprotein\tfound\tin\tserum\tand\tbody\tfluids;\tit\tinhibits\tserine\tproteinases.\tCholestasis\tor\tcirrhosis\tis\tcaused\tby\tthis\ndeficiency,\tand\tthere\tis\tno\ttreatment\texcept\tliver\ttransplantation.\nOther\tliver\tdiseases\nLiver\tdisease\tcan\tbe\tcaused\tby\tseveral\tconditions\tother\tthan\tthose\talready\tdiscussed.\tLiver\ttumors\tcan\tbe\tprimary
|
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or\tmetastatic,\tbenign\tor\tmalignant.\tHepatocellular\n\tcarcinoma\t(HCC)\tusually\tdevelops\tin\tcirrhotic\tlivers\twith\thighest\nrisk\tin\tindividuals\twith\thepatitis\tB\tvirus\t(HBV),\thepatitis\tC\tvirus\t(HCV),\tor\tNAFLD\t(\nKelly\tand\tVenook,\t2015\n).\tThe\nliver\talso\tcan\tbe\taffected\tby\trheumatic\tdiseases\tsuch\tas\trheumatoid\tarthritis,\tsystemic\tlupus\terythematosus,
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] |
polymyalgia,\ttemporal\tarteritis,\tpolyarteritis\tnodosa,\tsystemic\tsclerosis,\tand\tSjögren\tsyndrome\t(see\t\nChapter\t38\n).\nWhen\thepatic\tblood\tflow\tis\taltered—as\tin\tacute\tischemic\tand\tchronic\tcongestive\thepatopathy,\tBudd-Chiari\tsyndrome,\nand\thepatic\tvenoocclusive\tdisease—dysfunction\toccurs.\tIndividuals\twith\thepatic\tor\tportal\tvein\tthromboses\tshould\tbe
|
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] |
evaluated\tfor\ta\tmyeloproliferative\tdisorder.\tParasitic,\tbacterial,\tfungal,\tand\tgranulomatous\tliver\tdiseases\talso\toccur.\nFinally,\tcryptogenic\tcirrhosis\tis\tany\tcirrhosis\n\tfor\twhich\tthe\tcause\tis\tunknown.\nClassifying\tliver\tdisease\taccording\tto\tduration
|
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Classifying\tliver\tdisease\taccording\tto\tduration\nLiver\tdisease\tcan\tbe\tclassified\taccording\tto\tthe\ttime\tof\tonset\tand\tduration\tof\tthe\tdisease.\tLiver\tdisease\tcan\tbe\nfulminant,\tacute,\tand\tchronic.\nFulminant\thepatitis\tis\ta\tsyndrome\tin\twhich\tsevere\tliver\tdysfunction\tis\taccompanied\tby\t\nhepatic\tencephalopathy\n,
|
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] |
hepatic\tencephalopathy\n,\na\tclinical\tsyndrome\tcharacterized\tby\timpaired\tmentation,\n\tneuromuscular\tdisturbances,\tand\taltered\tconsciousness.\nFulminant\tliver\tdisease\n\tis\tdefined\tby\tthe\tabsence\tof\tpreexisting\tliver\tdisease\tand\tthe\trapid\tdevelopment\tof\thepatic
|
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] |
encephalopathy\twithin\t2\tto\t8\tweeks\tof\tthe\tonset\tof\tillness.\tThe\tmain\tcause\tof\tfulminant\thepatitis\tis\tviral\thepatitis;\nhowever,\tchemical\ttoxicity\t(e.g.,\tacetaminophen,\tdrug\treactions,\tpoisonous\tmushrooms,\tindustrial\tpoisons),\n\tand\nother\tcauses\t(e.g.,\tWilson’s\tdisease,\tfatty\tliver\tof\tpregnancy,\tReye\tsyndrome,\thepatic\tischemia,\thepatic\tvein
|
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] |
obstruction,\tand\tdisseminated\tmalignancies)\tare\texamples\tof\tother\tcauses.\tExtrahepatic\tcomplications\tof\tfulminant\nhepatitis\tare\tcerebral\tedema,\tcoagulopathy\tand\tbleeding,\tcardiovascular\tabnormalities,\trenal\tfailure,\tpulmonary\ncomplications,\tacid-base\tdisturbances,\telectrolyte\timbalances,\n\tsepsis,\tand\t\npancreatitis\n\t(inflammation\tof\tthe\npancreas).
|
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0.10076585412025452,
0.08548960834741592,
0.02383560687303543
] |
sepsis,\tand\t\npancreatitis\n\t(inflammation\tof\tthe\npancreas).\nAcute\tliver\tdisease\tis\tidentified\ttypically\tas\tliver\tdysfunction\tthat\thas\tbeen\tpresent\tfor\tless\tthan\t6\tmonths.\nRecovery\tis\texpected\tin\ta\tmajority\tof\tpatients\twho\tdevelop\tacute\tliver\tdisease.
|
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] |
To\tbe\tdiagnosed\twith\tchronic\thepatitis,\ta\tpatient\tmust\thave\tat\tleast\ta\t6-month\tcourse\tof\thepatitis\tor\tbiochemical\nand\tclinical\tevidence\tof\tliver\tdisease\n\twith\tconfirmatory\tbiopsy\tfindings\tof\tunresolving\thepatic\tinflammation.\tChronic\nhepatitis\tcan\tbe\tcaused\tby\tautoimmune\tdisease,\tviral\tinfections,\tmetabolic\tdisorders,\talcohol,\tdrugs,\tor\ttoxins.\tThe
|
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] |
most\tcommon\tcauses\tof\tchronic\thepatitis\tare\thepatitis\tB,\thepatitis\tC,\tand\tautoimmune\thepatitis.\tOther\tcauses\tare\ndrug-induced\tliver\tdisease,\tmetabolic\tdiseases,\tand\tNASH.\nClinical\tsymptoms\tof\tchronic\n\thepatitis\tare\tusually\tnonspecific,\toccur\tintermittently,\tand\tare\tmild.\tCommon
|
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] |
symptoms\tinclude\tfatigue,\tsleep\tdisorders,\tdifficulty\tconcentrating,\tand\tmild\tright\tupper\tquadrant\tpain.\tSevere\nadvanced\tdisease\tcan\tlead\tto\tjaundice,\tmuscle\twasting,\ttea-colored\turine,\tascites\t(fluid\taccumulation\tin\tthe\nabdomen),\tedema\t(fluid\taccumulation\tin\tthe\ttissues),\thepatic\tencephalopathy,\tgastrointestinal\t\nvarices\n\t(abnormal
|
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] |
varices\n\t(abnormal\nenlarged\tveins\toften\tcaused\tby\tportal\thypertension)\twith\tresultant\tgastrointestinal\tbleeding,\tsplenomegaly,\tpalmar\nerythema\t(red\tpalms),\tand\tspider\tangiomas\t(broken\tblood\tvessels).\nIn\tsome\tinstances,\tchronic\thepatitis\tleads\tto\tcirrhosis\tand\tliver\tfailure,\talso\tknown\tas\t\nend-stage\tliver\tdisease\n(ESLD)\n.\t\nCirrhosis
|
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] |
end-stage\tliver\tdisease\n(ESLD)\n.\t\nCirrhosis\n,\ta\tbuild\tup\tof\tscar\ttissue\tand\tfibrosis\tof\tthe\tliver,\thas\tmany\tclinical\tmanifestations,\n\tas\tillustrated\nin\t\nFig.\t28.4\n.\tThere\tare\tseveral\tmajor\tcomplications\tof\tcirrhosis\tand\tESLD.
|
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] |
FIG.\t28.4\nClinical\tmanifestations\tof\tcirrhosis.\nComplications\tof\tesld:\tCause\tand\tnutrition\ttreatment\nDecompensated\tESLD\tcan\thave\tseveral\tphysical\tmanifestations,\tincluding\tportal\thypertension,\tascites\tand\tedema,\nhyponatremia,\tand\thepatic\tencephalopathy.\tIt\tis\timportant\tto\tunderstand\tthe\tunderlying\tcause\tof\tthese\tcomplications
|
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as\twell\tas\tthe\tmedical\tand\tnutrition\ttreatment\toptions.\nPortal\thypertension\nPathophysiology\tand\tmedical\ttreatment\nPortal\thypertension\n\tincreases\tcollateral\tblood\tflow\tand\tcan\tresult\tin\tswollen\tveins\t(varices)\tin\tthe\tgastrointestinal\ntract\t(GIT).\tThese\tvarices\toften\tbleed,\tcausing\ta\tmedical\temergency.\tTreatment\tincludes\tadministration\tof\talpha-
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] |
adrenergic\tblockers\tto\tdecrease\theart\trate,\tendoscopic\tvariceal\tbanding,\tand\tradiologic\tplacement\tof\tshunts.\n\tA\ntransjugular\tintrahepatic\tportosystemic\tshunt\t(TIPS)\tinvolves\ta\tradiologically\tplaced\tstent\tbetween\tthe\tportal\tvein\nand\tthe\thepatic\tvein.\tDuring\tan\tacute\tbleeding\tepisode,\tsomatostatin\tor\tits\tanalog\tmay\tbe\tadministered\tto\tdecrease
|
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] |
bleeding,\tor\ta\tnasogastric\ttube\tequipped\twith\tan\tinflatable\tballoon\tis\tplaced\tto\talleviate\tbleeding\tfrom\tvessels.\nMedical\tnutrition\ttherapy\nDuring\tacute\tbleeding\n\tepisodes,\tnutrition\tcannot\tbe\tadministered\tenterally\t(using\tthe\tgut);\tparenteral\tnutrition\t(PN)\nis\tindicated\tif\ta\tpatient\twill\tbe\ttaking\tnothing\tenterally\tfor\tat\tleast\t5\tto\t7\tdays\t(see
|
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] |
Chapter\t12\n).\tRepeated\tendoscopic\ntherapies\tmay\tcause\tesophageal\tstrictures\tor\timpair\ta\tpatient’s\tswallowing.\tFinally,\tplacement\tof\tshunts\tmay\nincrease\tthe\tincidence\tof\tencephalopathy\tand\treduce\tnutrient\tmetabolism\n\tbecause\tblood\tis\tshunted\tpast\tthe\tliver\ncells.\nAscites\nPathophysiology\tand\tmedical\ttreatment\nFluid\tretention\tis\tcommon,\tand\t\nascites
|
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] |
Fluid\tretention\tis\tcommon,\tand\t\nascites\n\t(accumulation\tof\tfluid\tin\tthe\tabdominal\tcavity)\tis\ta\tserious\tconsequence\tof\nliver\tdisease.\tPortal\thypertension,\thypoalbuminemia,\tlymphatic\tobstruction,\tand\trenal\tretention\tof\tsodium\tand\tfluid\ncontribute\tto\tfluid\tretention.\tIncreased\trelease\tof\tcatecholamines,
|
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] |
contribute\tto\tfluid\tretention.\tIncreased\trelease\tof\tcatecholamines,\n\trenin,\tangiotensin,\taldosterone,\tand\tantidiuretic\nhormone\tsecondary\tto\tperipheral\tarterial\tvasodilation\tcauses\trenal\tretention\tof\tsodium\tand\twater.\nLarge-volume\t\nparacentesis\n\t(a\tprocedure\tto\tdrain\tthe\tfluid)\tmay\tbe\tused\tto\trelieve\tascites.\tDiuretic\ttherapy\toften
|
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is\tused\tand\tfrequently\tincludes\tthe\tmedications\tspironolactone\tand\tfurosemide.\tThese\tdrugs\toften\tare\tused\tin\ncombination\tfor\tbest\teffect.\n\tMajor\tside\teffects\tof\tloop\tdiuretics\tsuch\tas\tfurosemide\tinclude\thyponatremia,\nhypokalemia,\thypomagnesemia,\thypocalcemia,\tand\thypochloremic\tacidosis.\tBecause\tspironolactone\tis\tpotassium
|
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sparing,\tserum\tpotassium\tlevels\tmust\tbe\tmonitored\tcarefully\tand\tsupplemented\tor\trestricted\tif\tnecessary\tbecause\ndeficiency\tor\texcess\tcan\tcontribute\tto\tmetabolic\tabnormalities,\tincluding\tcardiac\tarrhythmias.\tWeight,\n\tabdominal\ngirth\t(due\tto\tfluid\taccumulation),\turinary\tsodium\tconcentration,\tand\tserum\tlevels\tof\turea\tnitrogen,\tcreatinine,
|
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] |
albumin,\turic\tacid,\tand\telectrolytes\tshould\tbe\tmonitored\tduring\tdiuretic\ttherapy.\nMedical\tnutrition\ttherapy\nDietary\ttreatment\tfor\tascites\tincludes\trestricting\tdietary\tsodium\tto\t2\tg/day\t(see\t\nAppendix\t46\n).\tMore\tsevere\nlimitations\tmay\tbe\timposed;\thowever,\tcaution\tis\twarranted\n\tbecause\tof\tlimited\tpalatability\tand\tthe\trisk\tof
|
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0.06575655192136765,
0.04601050168275833,
0.06553047895431519,
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] |
because\tof\tlimited\tpalatability\tand\tthe\trisk\tof\noverrestricting\tsodium,\twhich\tcan\tlead\tto\tinsufficient\tintake\tof\tsodium,\tor\tlimited\tintake\tof\tcalories\tand\tprotein.\nAdequate\tprotein\tintake\tis\talso\timportant\tto\treplace\tlosses\tfrom\tfrequent\tparacentesis.\nHyponatremia\nPathophysiology
|
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] |
Hyponatremia\nPathophysiology\nHyponatremia\t(low\tsodium\tlevel\tin\tthe\tblood)\toften\toccurs\tbecause\tof\tdecreased\tability\tto\texcrete\twater\tresulting\nfrom\tthe\tpersistent\trelease\tof\tantidiuretic\thormone,\tsodium\tlosses\tvia\tparacentesis,\texcessive\tdiuretic\tuse,\tor\toverly\naggressive\tsodium\trestriction.\nMedical\tnutrition\ttherapy
|
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to\tabout\t2\tg/day\tshould\nbe\tcontinued\tbecause\texcessive\tsodium\tintake\tresults\tin\tworsened\tfluid\tretention\tand\tthe\tfurther\tdilution\tof\tserum
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sodium\tlevels\t(hyponatremia).\nHepatic\tencephalopathy\nPathophysiology\tand\tmedical\ttreatment\nHepatic\tencephalopathy\n\tis\ta\tsyndrome\tcharacterized\tby\timpaired\tmentation,\tneuromuscular\tdisturbances,\tand\naltered\tconsciousness.\tGastrointestinal\tbleeding,\tfluid\n\tand\telectrolyte\tabnormalities,\turemia,\tinfection,\tuse\tof
|
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] |
and\telectrolyte\tabnormalities,\turemia,\tinfection,\tuse\tof\nsedatives,\thyperglycemia\tor\thypoglycemia,\talcohol\twithdrawal,\tconstipation,\tazotemia,\tdehydration,\tportosystemic\nshunts,\tand\tacidosis\tcan\tprecipitate\thepatic\tencephalopathy.\tSubclinical\tor\tminimal\thepatic\tencephalopathy\talso\naffects\tpatients\twith\tchronic\t\nhepatic\tfailure\n.\tHepatic\tor
|
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] |
affects\tpatients\twith\tchronic\t\nhepatic\tfailure\n.\tHepatic\tor\t\nportal\tsystemic\tencephalopathy\n\tresults\tin\nneuromuscular\n\tand\tbehavioral\talterations.\t\nBox\t28.1\n\tdescribes\tthe\tfour\tstages\tof\thepatic\tencephalopathy.\nBOX\t28.1\nFour\tStages\tof\tHepatic\tEncephalopathy\nStage\nSymptoms\nI
|
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] |
BOX\t28.1\nFour\tStages\tof\tHepatic\tEncephalopathy\nStage\nSymptoms\nI\nMild\tconfusion,\tagitation,\tirritability,\tsleep\tdisturbance,\tdecreased\tattention\nII\nLethargy,\tdisorientation,\tinappropriate\tbehavior,\tdrowsiness\nIII\nSomnolent\tbut\tarousable,\tincomprehensible\tspeech,\tconfused,\taggressive\tbehavior\n\twhen\tawake\nIV\nComa
|
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] |
when\tawake\nIV\nComa\nDifferent\ttheories\texist\tregarding\tthe\tmechanism\tby\twhich\thepatic\tencephalopathy\toccurs.\tHowever,\tone\tof\tthe\nmost\tcommon\ttheories\tinvolves\tammonia\taccumulation\tbecause\tit\tis\tconsidered\tto\tbe\tan\timportant\tcausal\tfactor\tin
|
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the\tdevelopment\tof\tencephalopathy.\tWhen\tthe\tliver\tfails,\tit\tis\tunable\tto\tdetoxify\tammonia\tto\turea.\tAmmonia\tlevels\nare\televated\tin\tthe\tbrain\tand\tbloodstream,\n\tleading\tto\timpaired\tneural\tfunction\tthrough\ta\tcomplex\tsystem.\tThe\tmain\nsource\tof\tammonia\tis\tits\tendogenous\tproduction\tby\tthe\tGIT\tfrom\tthe\tmetabolism\tof\tprotein\tand\tfrom\tthe\tdegradation
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] |
of\tbacteria\tand\tblood\tfrom\tgastrointestinal\tbleeding.\tExogenous\tprotein\tis\talso\ta\tsource\tof\tammonia.\tSome\tclinicians\nsuggest\tthat\tdietary\tprotein\tcauses\tan\tincrease\tin\tammonia\tlevels\tand\tsubsequently\thepatic\n\tencephalopathy,\tbut\tthis\nhas\tnot\tbeen\tproven\tin\tstudies.
|
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] |
encephalopathy,\tbut\tthis\nhas\tnot\tbeen\tproven\tin\tstudies.\nDrugs\tsuch\tas\tlactulose\tand\trifaximin\tare\tgiven\tto\ttreat\thepatic\tencephalopathy.\tLactulose\tis\ta\tnonabsorbable\ndisaccharide.\tIt\tacidifies\tthe\tcolonic\tcontents,\tretaining\tammonia\tas\tthe\tammonium\tion.\tIt\talso\tacts\tas\tan\tosmotic
|
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laxative\tto\tremove\tthe\tammonia.\tRifaximin\tis\ta\tnonabsorbable\tantibiotic\tthat\thelps\tdecrease\tcolonic\tammonia\nproduction.\nOne\tnutrition-related\thypothesis\tis\tthe\t“altered\tneurotransmitter\ttheory,”\twhich\tinvolves\tamino\tacid\timbalance.\tA\nplasma\tamino\tacid\timbalance\texists\tin\tESLD\tin\twhich\tthe\t\nbranched-chain\tamino\tacids\t(BCAAs)\n\tvaline,\tleucine,
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] |
branched-chain\tamino\tacids\t(BCAAs)\n\tvaline,\tleucine,\nand\tisoleucine\tare\tdecreased.\tThe\tBCAAs\tfurnish\tas\tmuch\tas\t30%\tof\tenergy\trequirements\tfor\tskeletal\tmuscle,\theart,\nand\tbrain\twhen\tgluconeogenesis\tand\tketogenesis\tare\tdepressed,\n\tcausing\tserum\tBCAA\tlevels\tto\tfall.\t\nAromatic\namino\tacids\t(AAAs)
|
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] |
causing\tserum\tBCAA\tlevels\tto\tfall.\t\nAromatic\namino\tacids\t(AAAs)\n\ttryptophan,\tphenylalanine,\tand\ttyrosine,\tplus\tmethionine,\tglutamine,\tasparagine,\tand\thistidine\nare\tincreased.\tPlasma\tAAAs\tand\tmethionine\tare\treleased\tinto\tcirculation\tby\tmuscle\tproteolysis,\tbut\tthe\tsynthesis
|
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into\tprotein\tand\tliver\tclearance\tof\tAAAs\tis\tdepressed.\tThis\tchanges\tthe\tplasma\tmolar\tratio\tof\tBCAAs\tto\tAAAs\tand\thas\nbeen\ttheorized\n\tto\tcontribute\tto\tthe\tdevelopment\tof\thepatic\tencephalopathy.\tConversely,\thigh\tlevels\tof\tAAAs\thave\nbeen\ttheorized\tto\tlimit\tthe\tcerebral\tuptake\tof\tBCAAs\tbecause\tthey\tcompete\tfor\tcarrier-mediated\ttransport\tat\tthe
|
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blood-brain\tbarrier.\tConvincing\tevidence\tto\tsupport\tthis\ttheory\tis\tlacking.\nMedical\tnutrition\ttherapy\nThe\toutdated\tpractice\tof\tprotein\trestriction\tin\tpatients\twith\tlow-grade\thepatic\tencephalopathy\n\tis\tbased\ton\tthe\npremise\tthat\tprotein\tintolerance\tcauses\thepatic\tencephalopathy,\tbut\tit\thas\tnever\tbeen\tproven\tin\ta\tstudy.\tTrue\tdietary
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protein\tintolerance\tis\trare\texcept\tin\tfulminant\thepatic\tfailure,\tor\tin\ta\trare\tpatient\twith\tchronic\tendogenous\thepatic\nencephalopathy.\tUnnecessary\tprotein\trestriction\tmay\tworsen\tbody\tprotein\tlosses\tand\tmust\tbe\tavoided.\tIn\tfact,\npatients\twith\tencephalopathy\n\toften\tdo\tnot\treceive\tadequate\tprotein.\tMost\tpatients\twith\tcirrhosis\tcan\ttolerate\tmixed-
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] |
protein\tdiets\tup\tto\t1.5\tg/kg\tof\tbody\tweight.\nStudies\tevaluating\tthe\tbenefit\tof\tsupplements\tenriched\twith\tBCAAs\tand\trestricted\tin\tAAAs\thave\tvaried\tin\tstudy\ndesign,\tsample\tsize,\tcomposition\tof\tformulas,\tlevel\tof\tencephalopathy,\ttype\tof\tliver\tdisease,\tduration\tof\ttherapy,\tand\ncontrol\tgroups.\tWhen\thigh–methodological
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] |
control\tgroups.\tWhen\thigh–methodological\n\tquality\tstudies\tare\tevaluated,\tno\tsignificant\timprovements\tor\tsurvival\nbenefits\tare\tassociated\twith\tgiving\textra\tBCAAs\tto\tpatients.\nOther\ttheories\tpostulate\tthat\tvegetable\tproteins\tand\tcasein\tmay\timprove\tmental\tstatus\tcompared\twith\tmeat
|
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protein.\tCasein-based\tdiets\tare\tlower\tin\tAAAs\tand\thigher\tin\tBCAAs\tthan\tmeat-based\tdiets.\tVegetable\tprotein\tis\tlow\tin\nmethionine\tand\tammoniagenic\tamino\tacids\tbut\n\tBCAA\trich.\tThe\thigh-fiber\tcontent\tof\ta\tvegetable-protein\tdiet\talso\nmay\tplay\ta\trole\tin\tthe\texcretion\tof\tnitrogenous\tcompounds.
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] |
may\tplay\ta\trole\tin\tthe\texcretion\tof\tnitrogenous\tcompounds.\nFinally,\tit\thas\tbeen\tproposed\tthat\tprobiotics\tand\tsynbiotics\t(sources\tof\tgut-friendly\tbacteria\tand\tfermentable\tfibers)\ncan\tbe\tused\tto\ttreat\thepatic\tencephalopathy.\tProbiotics\tmay\timprove\thepatic\tencephalopathy\tby\treducing\tammonia\nand\tendotoxin\tlevels.\tIn\ta\tmeta-analysis,
|
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] |
and\tendotoxin\tlevels.\tIn\ta\tmeta-analysis,\n\tprobiotics\twere\tshown\tto\treduce\tserum\tammonia\tlevels\tas\teffectively\tas\nlactulose\t(\nCai\tet\tal,\t2018\n)\tand\timprove\tminimal\thepatic\tencephalopathy\t(\nCao\tet\tal,\t2018\n;\t\nDalal\tet\tal,\t2017\n).\tThey\ndecrease\tinflammation\tand\toxidative\tstress\tin\tthe\thepatocyte\t(thus\tincreasing\thepatic\tclearance\tof\ttoxins\tincluding
|
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ammonia),\tand\tminimize\tuptake\tof\tother\ttoxins.\nGlucose\talterations\nPathophysiology\nGlucose\n\tintolerance\toccurs\tin\talmost\ttwo\tthirds\tof\tpatients\twith\tcirrhosis,\tand\tas\tmany\tas\tone\tthird\tof\tpatients\ndevelop\tdiabetes\tmellitus.\tGlucose\tintolerance\tin\tpatients\twith\tliver\tdisease\toccurs\tbecause\tof\tinsulin\tresistance\tin
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] |
peripheral\ttissues.\tHyperinsulinism\talso\toccurs\tin\tpatients\twith\tcirrhosis,\tpossibly\tbecause\tinsulin\tproduction\tis\nincreased,\thepatic\tclearance\tis\tdecreased,\tportal\tsystemic\n\tshunting\toccurs,\tthere\tis\ta\tdefect\tin\tthe\tinsulin-binding\naction\tat\tthe\treceptor\tsite,\tor\tthere\tis\ta\tpostreceptor\tdefect.\nFasting\thypoglycemia
|
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] |
Fasting\thypoglycemia\n,\tor\tlow\tblood\tglucose,\tcan\toccur\tbecause\tof\tthe\tdecreased\tavailability\tof\tglucose\tfrom\nglycogen\tin\taddition\tto\tthe\tfailing\tgluconeogenic\tcapacity\tof\tthe\tliver\twhen\tthe\tpatient\thas\tESLD.\tHypoglycemia\noccurs\tmore\toften\tin\tacute\tor\tfulminant\tliver\tfailure\n\tthan\tin\tchronic\tliver\tdisease.\tHypoglycemia\talso\tmay\toccur\tafter
|
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than\tin\tchronic\tliver\tdisease.\tHypoglycemia\talso\tmay\toccur\tafter\nalcohol\tconsumption\tin\tpatients\twhose\tglycogen\tstores\tare\tdepleted\tby\tstarvation\tbecause\tof\tthe\tblock\tof\thepatic\ngluconeogenesis\tby\tethanol.\nMedical\tnutrition\ttherapy
|
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] |
Patients\twith\tdiabetes\tmellitus\tshould\treceive\tstandard\tmedical\tand\tnutrition\ttherapy\tto\tachieve\tnormoglycemia\t(see\nChapter\t29\n).\tPatients\twith\thypoglycemia\tneed\n\tto\teat\tfrequently\tto\tprevent\tthis\tcondition\t(see\t\nClinical\tInsight:\n\tFasting\nHypoglycemia\n).\tEvening\tsnacks\tthat\tcontain\tlow\tglycemic\tcarbohydrates\tbalanced\twith\tprotein\tmay\thelp\tprevent
|
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broken\tdown,\tor\tnew\tglucose\tis\tmade\tfrom\tnonglucose\tamino\tacid\tprecursors\tsuch\tas\talanine.\tFasting\nhypoglycemia\toccurs\tin\tliver\tand\tbiliary\tdisease\twhen\tthere\tis\treduced\tsynthesis\tof\tnew\tglucose\tor\treduced\tliver\nglycogen\tbreakdown.\nCauses\tof\tfasting\thypoglycemia\tinclude\tcirrhosis,\tconsumption\tof\talcohol,\textensive\tintrahepatic\n\tcancer,
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cancer,\ndeficiency\tof\tcortisol\tand\tgrowth\thormone,\tor\tnon–beta-cell\ttumors\tof\tthe\tpancreas\t(insulinomas).\tAll\tpatients\nwith\tliver\tor\tpancreatic\tdisease\tshould\tbe\tmonitored\tfor\tfasting\thypoglycemia.\tNutrition\ttherapy\tinvolves\nbalanced\tmeals\twith\tsmall,\tfrequent\tsnacks\tto\tavoid\tperiods\tof\tfasting.\tMonitoring\tof\tblood\tglucose\tand\tinsulin
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] |
levels\tis\trequired.\nFat\tmalabsorption\nPathophysiology\nFat\tabsorption\tmay\tbe\timpaired\tin\tliver\tdisease.\tPossible\tcauses\tinclude\tdecreased\tbile\tsalt\tsecretion\t(as\tin\tPBC,\nsclerosing\tcholangitis,\tand\tbiliary\tstrictures),\tadministration\tof\tmedications\tsuch\tas\tcholestyramine,\tand\tpancreatic
|
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0.07703963667154312,
-0.05977544188499451,
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0.11413291096687317,
0.07275746017694473,
-0.11412221938371658,
-0.026633910834789276,
0.12035385519266129,
-0.045805856585502625,
-0.01506279967725277,
-0.08613589406013489,
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0.07140793651342392,
0.06962328404188156,
0.005330308340489864,
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0.08980182558298111,
0.11682793498039246,
0.06406550109386444,
-0.03653371334075928
] |
enzyme\tinsufficiency.\tStools\tmay\tbe\tgreasy,\tfloating,\tor\tlight-\tor\tclay-colored,\tsignifying\tmalabsorption,\twhich\tcan\tbe\nverified\tby\ta\t72-hour\tfecal\tfat\tstudy\t(see\t\nChapter\t27\n).\nMedical\tnutrition\ttherapy\nIf\tsignificant\t\nsteatorrhea\n\t(the\tpresence\tof\tfat\tin\tthe\tstool)\tis\tpresent,\treplacement\tof\tsome\tof\tthe\tlong-chain
|
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] |
triglycerides\tor\tdietary\tfat\twith\tmedium-chain\ttriglycerides\t(MCTs)\tcan\tbe\tuseful.\tBecause\tMCTs\tdo\tnot\trequire\tbile\nsalts\tand\tmicelle\tformation\tfor\tabsorption,\tthey\tare\treadily\ttaken\tup\tvia\tthe\tportal\troute.\tSome\tnutrition\tsupplements\ncontain\tMCTs,\twhich\n\tcan\tbe\tused\tin\taddition\tto\tliquid\tMCT\toil\t(see\t\nChapter\t12\n).
|
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] |
can\tbe\tused\tin\taddition\tto\tliquid\tMCT\toil\t(see\t\nChapter\t12\n).\nSignificant\tstool\tfat\tlosses\tmay\twarrant\ta\ttrial\tof\ta\tlow-fat\tdiet\tor\tevaluation\tof\tpancreatic\tinsufficiency.\tIf\tdiarrhea\ndoes\tnot\tresolve,\tfat\trestriction\tshould\tbe\tdiscontinued\tbecause\tit\tdecreases\tthe\tpalatability\tof\tthe\tdiet\tand\tmakes\tit
|
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] |
difficult\tto\ttake\tin\tadequate\tcalories.\tBecause\tof\tthe\tdegree\tof\tmalabsorption\tand\tsteatorrhea,\n\tit\tis\timportant\tto\nconsider\tthat\tthe\tpatient\tmay\thave\tdeficiencies\tof\tmultiple\tmicronutrients,\tespecially\tfat-soluble\tvitamins.\nRenal\tinsufficiency\tand\thepatorenal\tsyndrome\nPathophysiology,\tmedical,\tand\tnutrition\ttherapies\nHepatorenal\tsyndrome
|
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] |
Hepatorenal\tsyndrome\n\tis\trenal\tfailure\tassociated\twith\tsevere\tliver\tdisease\twithout\tintrinsic\tkidney\tabnormalities.\nHepatorenal\tsyndrome\tis\tdiagnosed\twhen\tthe\turine\tsodium\n\tlevel\tis\tless\tthan\t10\tmEq/L\tand\toliguria\tpersists\tin\tthe\nabsence\tof\tintravascular\tvolume\tdepletion.\tIf\tconservative\ttherapies,\tincluding\tdiscontinuation\tof\tnephrotoxic\tdrugs,
|
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0.010696322657167912
] |
optimization\tof\tintravascular\tvolume\tstatus,\ttreatment\tof\tunderlying\tinfection,\tand\tmonitoring\tof\tfluid\tintake\tand\noutput\tfail,\tdialysis\tmay\tbe\trequired.\tIn\tany\tcase,\trenal\tinsufficiency\tand\tfailure\tmay\tnecessitate\talteration\n\tin\tfluid,\nsodium,\tpotassium,\tand\tphosphorus\tintake\t(see\t\nChapter\t34\n).\nOsteopenia\nPathophysiology
|
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] |
Chapter\t34\n).\nOsteopenia\nPathophysiology\nOsteopenia\toften\texists\tin\tpatients\twith\tPBC,\tsclerosing\tcholangitis,\tand\talcoholic\tliver\tdisease.\tDepressed\nosteoblastic\tfunction\tand\tosteoporosis\talso\tcan\toccur\tin\tpatients\twith\themochromatosis,\tand\tosteoporosis\tis\nprevalent\tin\tpatients\twho\thave\thad\tlong-term\ttreatment\twith\tcorticosteroids.
|
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] |
Corticosteroids\tincrease\tbone\nresorption;\tsuppress\tosteoblastic\tfunction;\tand\taffect\tsex\thormone\tsecretion,\tintestinal\tabsorption\tof\tdietary\tcalcium,\nrenal\texcretion\tof\tcalcium\tand\tphosphorus,\tand\tvitamin\tD.\nMedical\tnutrition\ttherapy\nPrevention\tor\ttreatment\toptions\tfor\tosteopenia\tinclude\tprevention\tof\texcessive\tweight\tloss,\tingestion\tof\ta\twell-
|
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] |
balanced\tdiet,\tadequate\tprotein\tto\tmaintain\tmuscle\n\tmass,\ta\tminimum\tof\tthe\tdietary\treference\tintake\t(DRI)\tfor\ncalcium\tper\tday\t(1000\tto\t1300\tmg\tdepending\ton\tage),\tadequate\tvitamin\tD\tfrom\tthe\tdiet\tor\tsupplements,\tavoidance\nof\talcohol,\tand\tmonitoring\tfor\tsteatorrhea,\twith\tdiet\tadjustments\tas\tneeded\tto\tminimize\tnutrient\tlosses.
|
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] |
Nutrition\tissues\trelated\tto\tend-stage\tliver\tdisease\nNutrition\tassessment\nNutrition\tassessment\tmust\tbe\tperformed\tto\n\tdetermine\tthe\textent\tand\tcause\tof\tmalnutrition\tin\tpatients\twith\tliver\ndisease.\tHowever,\tmany\ttraditional\tmarkers\tof\tnutrition\tstatus\tare\taffected\tby\tliver\tdisease,\tmaking\ttraditional\nassessment\tdifficult.\t\nTable\t28.3
|
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] |
assessment\tdifficult.\t\nTable\t28.3\n\tsummarizes\tthe\tfactors\tthat\taffect\tinterpretation\tof\tnutrition\tassessment\tparameters\nin\tpatients\twith\tliver\tdysfunction.
|
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] |
TABLE\t28.3\nFactors\tThat\tAffect\tInterpretation\tof\tObjective\n\tNutrition\tAssessment\tParameter\tin\tPatients\tWith\tEnd-Stage\tLiver\tDisease\nParameter\nFactors\tAffecting\tInterpretation\nBody\tweight\nAffected\tby\tedema,\tascites,\tand\tdiuretic\tuse\nAnthropometric\tmeasurements\nQuestionable\tsensitivity,\tspecificity,\tand\treliability\nMultiple\tsources\tof\terror
|
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Multiple\tsources\tof\terror\nUnknown\tif\tskinfold\tmeasurements\treflect\ttotal\tbody\tfat\nReferences\tdo\tnot\taccount\tfor\tvariation\tin\n\thydration\tstatus\tand\tskin\ncompressibility\nNitrogen\tbalance\tstudies\nNitrogen\tis\tretained\tin\tthe\tbody\tin\tthe\tform\tof\tammonia\nHepatorenal\tsyndrome\tcan\taffect\tthe\texcretion\tof\tnitrogen\nSingle-frequency\tbioelectrical\nimpedance
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] |
Single-frequency\tbioelectrical\nimpedance\nInvalid\twith\tascites\tand\tedema\nModified\tfrom\tHasse\tJ:\tNutritional\taspects\tof\tadult\tliver\ttransplantation.\tIn\tBusuttil\tRW,\tKlintmalm\tGB,\teditors:\t\nTransplantation\tof\n\tthe\tliver\n,\ted\t3,\tPhiladelphia,\t2015,\tElsevier\nSaunders.
|
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] |
the\tliver\n,\ted\t3,\tPhiladelphia,\t2015,\tElsevier\nSaunders.\nObjective\tnutrition\tassessment\tparameters\tthat\tare\thelpful\twhen\tmonitored\tserially\tinclude\tanthropometric\nmeasurements\tand\tdietary\tintake\tevaluation\t(see\t\nChapters\t4\n\tand\t\n5\n).\tCaution\tshould\tbe\ttaken\twhen\tassessing
|
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] |
Chapters\t4\n\tand\t\n5\n).\tCaution\tshould\tbe\ttaken\twhen\tassessing\nbiochemical\tmarkers\tin\tthe\tadvanced\tliver\tdisease\tpatient\tbecause\tthe\ttypical\tnutrition\tcriteria\twill\tbe\taffected\tdue\nto\tthe\n\tliver\tdisease\titself.\tThe\tbest\tway\tto\tperform\ta\tnutrition\tassessment\tmay\tbe\tto\tcombine\tthese\tparameters\twith
|
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] |
the\tsubjective\tglobal\tassessment\t(SGA)\tapproach,\twhich\thas\tdemonstrated\tan\tacceptable\tlevel\tof\treliability\tand\nvalidity.\tThe\tSGA\tgives\ta\tbroad\tperspective,\tbut\tit\tis\tnot\tsensitive\tto\tchanges\tin\tnutrition\tstatus.\tOther\tavailable\nparameters\tshould\talso\tbe\treviewed.\tThe\tSGA\tapproach\tis\tsummarized\n\tin\t\nBox\t28.2\n.\nBOX\t28.2
|
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] |
in\t\nBox\t28.2\n.\nBOX\t28.2\nSubjective\tGlobal\tAssessment\tParameters\tfor\tNutrition\tEvaluation\tof\nLiver\tDisease\tPatients\nHistory\nWeight\tchange\t(consider\tfluctuations\tresulting\tfrom\tascites\tand\tedema)\nAppetite\nTaste\tchanges\tand\tearly\tsatiety\nDietary\tintake\t(calories,\tprotein,\tsodium)
|
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] |
Dietary\tintake\t(calories,\tprotein,\tsodium)\nPersistent\tgastrointestinal\tproblems\t(nausea,\tvomiting,\tdiarrhea,\tconstipation,\tdifficulty\tchewing\tor\nswallowing)\nPhysical\tfindings\nMuscle\twasting\nFat\tstores\nAscites\tor\tedema\nExisting\tconditions\nDisease\tstate\tand\tother\tproblems\tthat\tcould\tinfluence\tnutrition\tstatus\tsuch\tas\thepatic\tencephalopathy,
|
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] |
gastrointestinal\tbleeding,\trenal\tinsufficiency,\tinfection\nNutritional\trating\tbased\ton\tresults\nWell\tnourished\nModerately\t(or\tsuspected\tof\tbeing)\tmalnourished\nSeverely\tmalnourished\nFrom\tHasse\n\tJ:\tNutritional\taspects\tof\tadult\tliver\ttransplantation.\tIn:\tBusuttil\tRW,\tKlintmalm\tGB,\teditors:\t\nTransplantation\tof\nthe\tliver,
|
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] |
Transplantation\tof\nthe\tliver,\n\ted\t2,\tPhiladelphia,\t2005,\tElsevier\tSaunders.\nMalnutrition\nModerate\tto\tsevere\tmalnutrition\tis\ta\tcommon\tfinding\tin\tpatients\twith\tadvanced\tliver\tdisease\t(\nFig.\t28.5\n).\tThis\tis\nextremely\tsignificant,\tconsidering\tthat\tmalnutrition\tplays\ta\tmajor\trole\tin\tthe\tpathogenesis\n\tof\tliver\tinjury\tand\thas\ta
|
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] |
of\tliver\tinjury\tand\thas\ta\nprofound\tnegative\teffect\ton\tprognosis.\tThe\tprevalence\tof\tmalnutrition\tdepends\ton\tnutrition\tassessment\tparameters\nused,\ttype\tand\tdegree\tof\tliver\tdisease,\tand\tsocioeconomic\tstatus.
|
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] |
FIG.\t28.5\nSevere\tmalnutrition\tand\tascites\tin\ta\tman\twith\tend-stage\tliver\tdisease.\nNumerous\tcoexisting\tfactors\tare\tinvolved\tin\tthe\tdevelopment\tof\tmalnutrition\tin\tliver\tdisease\t(see\t\nPathophysiology\nand\tCare\tManagement\tAlgorithm:\n\tMalnutrition\tin\tLiver\tDisease\n).\tInadequate\toral\tintake,\ta\tmajor\tcontributor,\tis
|
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).\tInadequate\toral\tintake,\ta\tmajor\tcontributor,\tis\ncaused\tby\tanorexia,\tdysgeusia,\tearly\tsatiety,\tnausea,\tor\tvomiting\tassociated\twith\tliver\n\tdisease\tand\tthe\tdrugs\tused\tto\ntreat\tit.\tAnother\tcause\tof\tinadequate\tintake\tis\tdietary\trestriction.\nMaldigestion\tand\tmalabsorption\talso\tplay\ta\trole.\t\nSteatorrhea
|
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Maldigestion\tand\tmalabsorption\talso\tplay\ta\trole.\t\nSteatorrhea\n\tis\tcommon\tin\tcirrhosis,\tespecially\tif\tthere\tis\tdisease\ninvolving\tbile\tduct\tinjury\tand\tobstruction.\tMedications\talso\tmay\tcause\tspecific\tmalabsorptive\tlosses.\tIn\taddition,\naltered\tmetabolism\tsecondary\tto\tliver\tdysfunction\tcauses\tmalnutrition\n\tin\tvarious\tways.\tMicronutrient\tfunction\tis
|
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in\tvarious\tways.\tMicronutrient\tfunction\tis\naffected\tby\taltered\tstorage\tin\tthe\tliver,\tdecreased\ttransport\tby\tliver-synthesized\tproteins,\tand\trenal\tlosses\tassociated\nwith\talcoholism\tand\tadvanced\tliver\tdisease.\tAbnormal\tmacronutrient\tmetabolism\tand\tincreased\tenergy\texpenditure
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] |
also\tcan\tcontribute\tto\tmalnutrition.\tFinally,\tprotein\tlosses\tcan\toccur\tfrom\tlarge-volume\tparacentesis\twhen\tseveral\nliters\n\tof\tfluid\tfrom\tthe\tabdomen\t(ascites)\tare\tremoved\tthrough\ta\tneedle.\nRoute\tof\tnutrition\nAlthough\toral\tdiet\tis\tthe\tpreferred\troute\tof\tnutrition\tfor\tpatients\twith\tESLD,\tanorexia,\tnausea,\tdysgeusia,\tand\tother
|
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] |
gastrointestinal\tsymptoms\tcan\tmake\tadequate\tnutrition\tintake\tdifficult\tto\tachieve.\tEarly\tsatiety\tis\talso\ta\tfrequent\ncomplaint\tsuch\tthat\tsmaller,\tmore\tfrequent\tmeals\tare\tbetter\ttolerated\tthan\tthree\tlarge\tmeals.\tIn\taddition,\tfrequent\nfeedings\tmay\talso\timprove\n\tnitrogen\tbalance\tand\tprevent\thypoglycemia.\tNutrient-dense\tsnacks\tor\tsupplements\tin\tthe
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] |
the\tdisease.\tEnteral\tnutrition\t(EN)\tis\npreferred\tover\tparenteral\tnutrition\t(PN)\tand\thistory\tof\tvarices\tare\tusually\tnot\ta\tcontraindication\tfor\ttube\tfeeding\tvia\na\tnasoenteric\ttube,\tprovided\tthere\tis\tno\tactive\tbleeding\t(see\t\nPortal\tHypertension\n\t\nPathophysiology\tand\tMedical\nTreatment
|
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] |
Portal\tHypertension\n\t\nPathophysiology\tand\tMedical\nTreatment\n).\tGenerally,\tgastrostomy\tor\tjejunostomy\ttubes\tare\tnot\tviable\toptions\tin\tpatients\twith\tliver\tdisease\tgiven\ncommon\tcomplications\n\tof\tcirrhosis,\tincluding\tascites\tand\tgastric\tvarices.\tInstead,\ta\tnasoenteric\ttube\t(nasogastric,
|
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nasointestinal)\ttube\tis\tpreferred\talthough\tthose\tcould\tbe\tcontraindicated\tif\tthe\tpatient\thas\tsevere\tepistaxis.\nTreatment\nEN\tsupport\tmay\tbe\tnecessary\tin\tmalnourished\tpatients\tor\tpatients\twith\tinadequate\tnutrient\tintake.\tThe\tamount\tand\nduration\tof\tnutrition\tsupport\tdepends\ton\tthe\tgoals\tof\ttreatment\n\t(e.g.,\tproviding\tsupport\tduring\tan\tacute\tevent\tvs.
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] |
(e.g.,\tproviding\tsupport\tduring\tan\tacute\tevent\tvs.\nimproving\tnutrition\tto\tqualify\tfor\ttransplant),\tseverity\tof\tthe\tliver\tdisease\tand\tmalnutrition,\tand\tother\tcomorbidities\n(e.g.,\tinfection,\trenal\tinsufficiency,\thepatic\tencephalopathy,\tetc.).\tIf\timproved\tsurvival\tis\tconsidered\tthe\tdesired
|
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] |
outcome\tfor\tnutrition\tsupport,\tthere\tis\tno\tconsensus\ton\thow\tEN\taffects\tsurvival\tin\tthis\tpopulation.\tA\tmulticenter\nstudy\tthat\tevaluated\teffects\tof\tEN\tin\tpatients\twith\tcirrhosis\tand\tjaundice\tdid\tnot\tfind\tthat\tEN\twas\tassociated\twith\ta\nsurvival\tbenefit\t(\nDupont\tet\tal,\t2012
|
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] |
survival\tbenefit\t(\nDupont\tet\tal,\t2012\n).\tHowever,\ta\tmeta-analysis\tby\tNey\tet\tal.\t(2013)\tsuggested\tthat\tnutrition\ttherapy\nwas\tassociated\twith\treduced\tmortality\tin\tpatients\twith\tcirrhosis\tor\talcoholic\thepatitis\tdisease,\tbut\ta\tconcern\tof\tthe\nstudy\twas\thigh\trisk\tof\tbias\tamong\tthe\tstudies\n\tanalyzed.\tAdditional\tstudies\tare\trequired\tto\tdetermine\thow\tmuch
|
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] |
analyzed.\tAdditional\tstudies\tare\trequired\tto\tdetermine\thow\tmuch\nnutrition\tsupport\tis\tneeded\tand\tover\twhat\tperiod\tof\ttime\tto\timprove\tnutrition\tstatus\tor\tinfluence\tchosen\toutcomes.\nNutrient\trequirements\tfor\tcirrhosis\nEnergy\nEnergy\trequirements\tvary\tamong\tpatients\twith\tcirrhosis.\tSeveral\tstudies\thave\tmeasured\tresting\tenergy\texpenditure
|
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(REE)\tin\tpatients\twith\tliver\tdisease\tto\tdetermine\tenergy\n\trequirements.\tSome\tstudies\tfound\tthat\tpatients\twith\tESLD\nhad\tnormal\tmetabolism\tand\tthat\tothers\thad\thypometabolism\tor\thypermetabolism.\tAscites\tor\tshunt\tplacement\tmay\nincrease\tenergy\texpenditure\tslightly.
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increase\tenergy\texpenditure\tslightly.\nIn\tgeneral,\tenergy\trequirements\tfor\tpatients\twith\tESLD\tand\twithout\tascites\tare\tapproximately\t120%\tto\t140%\tof\nthe\tREE.\tRequirements\tincrease\tto\t150%\tto\t175%\tof\tREE\tif\tascites,\tinfection,\tand\tmalabsorption\n\tare\tpresent,\tor\tif
|
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] |
are\tpresent,\tor\tif\nnutritional\trepletion\tis\tnecessary\tdue\tto\tmalnutrition.\tThis\tequates\tto\tapproximately\t25\tto\t35\tcalories\tper\tkilogram\nbody\tweight,\talthough\tneeds\tcould\tbe\tas\tlow\tas\t20\tcalories\tper\tkilogram\tfor\tobese\tpatients\tand\tas\thigh\tas\t40\ncalories\tper\tkilogram\tfor\tunderweight\tpatients\t(\nAmodio\tet\tal,\t2013\n).\tEstimated\t\ndry\tbody\tweight
|
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] |
Amodio\tet\tal,\t2013\n).\tEstimated\t\ndry\tbody\tweight\n\t(i.e.,\tweight\nwithout\tfluid\tretention)\tor\tideal\tweight\tshould\n\tbe\tused\tin\tcalculations\tto\tprevent\toverfeeding.\nCarbohydrate\nDetermining\tcarbohydrate\tneeds\tis\tchallenging\tin\tliver\tfailure\tbecause\tof\tthe\tprimary\trole\tof\tthe\tliver\tin
|
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] |
carbohydrate\tmetabolism.\tLiver\tfailure\treduces\tglucose\tproduction\tand\tperipheral\tglucose\tuse.\tThe\trate\tof\ngluconeogenesis\tis\tdecreased,\twith\tpreference\tfor\tlipids\tand\tamino\tacids\tfor\tenergy.\tIn\taddition,\tinsulin\tresistance\ncan\n\tbe\tpresent\twith\tliver\tdysfunction.\nLipid
|
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] |
can\n\tbe\tpresent\twith\tliver\tdysfunction.\nLipid\nIn\tcirrhosis,\tplasma-free\tfatty\tacids,\tglycerol,\tand\tketone\tbodies\tare\tincreased\tin\tthe\tfasting\tstate.\tThe\tbody\tprefers\nlipids\tas\tan\tenergy\tsubstrate.\tLipolysis\tis\tincreased\twith\tactive\tmobilization\tof\tlipid\tdeposits,\tbut\tthe\tnet\tcapacity\tto
|
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] |
store\texogenous\tlipid\tis\tnot\timpaired.\tAn\taverage\tof\t30%\tof\tcalories\tas\tfat\tis\tsufficient,\tbut\tadditional\tfat\n\tcan\tbe\ngiven\tas\ta\tconcentrated\tsource\tof\tcalories\tfor\tthose\twho\tneed\tadditional\tcalories.\tIn\tpatients\twith\tsevere\nsteatorrhea,\tuse\tof\tMCT\toil\tcould\tbe\tconsidered.\nProtein
|
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] |
steatorrhea,\tuse\tof\tMCT\toil\tcould\tbe\tconsidered.\nProtein\nProtein\tis\tby\tfar\tthe\tmost\tcontroversial\tnutrient\tin\tliver\tfailure,\tand\tits\tmanagement\tis\talso\tthe\tmost\tcomplex.\nCirrhosis\thas\tlong\tbeen\tthought\tof\tas\ta\tcatabolic\tdisease\twith\tincreased\tprotein\tbreakdown,\tinadequate\tsynthesis,
|
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