Maintaining optimal nutritional status is important in the patient with end stage liver disease both pre-and post-transplant. However, nutritional assessment in end stage liver disease is particularly problematic. In the pretransplant setting, fluid retention, ascites, and hepatosplenomegaly make body weight an unreliable nutritional index. True decreases in body weight, due to loss of fat stores and lean body mass, may not be fully appreciated solely following weight trends. In the pediatric population, linear growth is often a better indicator of nutritional status. Chronic malnutrition is often present, as reflected in a decrease in linear growth velocity.
Although anthropometric measurements, 24-h creatinine, bioelectric impedance analysis, and indirect calorimetry have all been used, they are affected by ascites and peripheral edema. In vivo neutron activation analysis and isotope dilution techniques are more accurate ways of assessing body composition but are time-consuming and costly. For practical purposes, the indirect assessments of 24-h urinary creatinine excretion to determine body muscle mass and mid-arm muscle area can be used for patients without high volumes of extracellular fluid; in those with ascites, the creatinine-height index is a better way of assessing body muscle mass.
Visceral proteins, including albumin, transferrin, prealbumin, and retinol binding protein, are typically used in monitoring nutritional status due to the decrease seen in inadequate dietary protein intake. However, they should be used with caution in liver disease because the synthesis of these proteins is also decreased in end stage liver disease. Serum levels of fat-soluble vitamins should be monitored closely as well.
Improving nutritional status prior to transplant is imperative because malnutrition affects morbidity and mortality post-transplant. Although it may not be possible to reverse the degree of malnutrition, aggressive nutrition support should be implemented to prevent further worsening of the nutrition state and possibly reduce pre- and post-transplant infection and complications.
Post-transplant nutrition support should not be overlooked because the nutrition deficit is not cured merely by the transplant. Additionally, the surgery poses increased nutritional demand for post-surgery healing and support. Nutrition repletion may occur at a more rapid rate than pretransplant because the patient now has a functional liver in which metabolism and digestion of macro- and micronutrients will be improved.
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Pregnancy; Prevention of Neural Tube Defects; Pre-eclampsia and Diet. Vitamin A: Biochemistry and Physiological Role; Deficiency and Interventions. Vitamin D: Physiology, Dietary Sources and Requirements; Rickets and Osteomalacia. Vitamin E: Metabolism and Requirements.
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