KRONİK KARACİĞER HASTALIKLARINDA TIBBİ BESLENME TEDAVİSİ

Yıl 2017, Cilt: 6 Sayı: 1, 156 - 170, 31.03.2017

Kübra Esin , Fatma Nur Bingöl Gamze Akbulut

Öz

Kronik
karaciğer hastalarında malnütrisyon yaygın görülen bir komplikasyondur.
Hastalığın ilerlemesi ile birlikte malnütrisyon oranı artmaktadır. Malnütrisyon
temel olarak yetersiz ve/veya kalitesiz besin alımı, sindirim ve emilim
bozukluğu, dinlenme enerji harcamasının ve besin öğesi gereksinmesinin artması
sonucu görülmektedir. Malnütrisyonun neden
olabileceği komplikasyonları önlemek için kronik karaciğer hastalarında
malnütrisyon ve beslenme durumu değerlendirmesi yapılmalıdır. Hastaların
malnütrisyonunun tanımlanmasında ve beslenme durumunun değerlendirilmesinde
genellikle Subjektif Global Değerlendirme (SGA) yöntemi ve antropometrik
ölçümler (üst orta kol çevresi, el kavrama gücü, biyolelektrik impedans
yöntemi) kullanılmaktadır. Kronik karaciğer hastalarında malnütrisyonu önlemek
ve besin öğesi gereksinmelerini karşılamak amaçlı oral, enteral ve/veya parenteral yolla beslenme destek tedavileri uygulanmaktadır.
Beslenme tedavisi uygulanırken, hepatik ensefalopatinin ilerlemiş evreleri
hariç,  enerji ve protein kısıtlaması
yapılmamalıdır. Yine bu hastalarda az ve sık beslenmeye, düzenli gece öğünü
tüketimine dikkat edilmelidir. Kronik karaciğer hastalarında dallı zincirli
aminoasitlerin kullanımı hastalığın seyrini olumlu etkilemektedir. Alkolik
hepatitte N-asetil sisteinin; hepatik
ensefalopatide ise probiyotik ve L ornitin-aspartatın beslenme
tedavisinde alternatif olarak kullanımının olumlu sonuçlarına ilişkin
çalışmalar mevcut olup, konu ile ilgili yeni çalışmalara gereksinim
duyulmaktadır.  Sonuç olarak, yeterli ve uygun tıbbi beslenme tedavisi ile
hastaların klinik ve metabolik bulguları iyileşmekte, yaşam kaliteleri artmakta
ve sağ kalım süreleri uzamaktadır. Bu derleme çalışmada, güncel
literatür taramaları doğrultusunda kronik karaciğer hastalarının tıbbi beslenme
tedavisi üzerinde durulmuştur.

Anahtar Kelimeler

Kronik Karaciğer Hastalıkları, Beslenme, Malnütrisyon

Kaynakça

• Saunders, J., Brian, A., Wright, M., Stroud, M. (2010). “Malnutrition and nutrition support in patients with liver disease” Frontline Gastroenterol, 1(2): 105-11.
• Henkel, AS., Buchman, AL. (2006). “Nutritional support in patients with chronic liver disease” Nat Clin Pract Gastroenterol Hepatol, 3(4): 202-9.
• Patton, HM. (2012). “Nutritional Assessment of Patients with Chronic Liver Disease” Gastroenterol Hepatol, 8(10): 687-90.
• Taniguchi, E., Kawaguchi, T., Itou, M. ve ark. (2011). “Subjective global assessment is not sufficient to screen patients with defective hepatic metabolism” Nutrition, 27: 282–6.
• Tsiaousi, E.T., Hatzitolios, A.I., Trygonis, S.K., Savopoulos, C.G. (2008). “Malnutrition in end stage liver disease: Recommendations and nutritional support” J Gastroenterol Hepatol, 23(4): 527–33.
• Gao, B., Bateler, R. (2011). “Alcoholic Liver Disease: Pathogenesis and New Therapeutic Targets” Gastroenterology, 141(5): 1572–85.
• Teli, M.R., Day, C.P., Burt, A.D., Bennett, M.K., James, OF. (1995). Determinants of progression to cirrhosis or fibrosis in pure alcoholic fatty liver. Lancet, 346(8981): 987-90.
• Frazier, T.H., Stocker, A.M., Kershner, N.A., Marsano, L.S., McClain, C.J. (2011). “Treatment of alcoholic liver disease” Ther Adv Gastroenterol, 4(1): 63-81.
• Lucey, M.R., Mathurin, P., Morgan, T.R.(2009). “Alcoholic Hepatitis” N Engl J Med, 360(26): 2758-69.
• O’Shea, R.S., Dasarathy, S., McCullough, A.J. (2010). “Alcoholic Liver Disease” Hepatology, 51(1): 307-28.
• Liangpunsakul, S.,(2011). “Clinical characteristics and mortality of hospitalized alcoholic hepatitis patients in the United States” J Clin Gastroenterol, 45(8): 714-9.
• Sandahl, T.D., Jepsen, P., Thomsen, K.L., Vilstrup, H. (2011). “Incidence and mortality of alcoholic hepatitis in Denmark 1999–2008: a nationwide population based cohort study” J Hepatol, 54(4): 760–4.
• Babineaux, M.J., Anand, B.S. (2011). “General aspects of the treatment of alcoholic hepatitis” World J Hepatol, 3(5): 125-9.
• Plauth, M. (2010). “Nutritional support in liver disease” e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 5(2): 104-6.
• Plauth, M., Cabre´, E., Campillo, B., Kondrup, J., Marchesini, G., Schutz, T. (2009). “ESPEN Guidelines on Parenteral Nutrition: Hepatology” Clinical Nutrition, 28(4): 436–44.
• Mezey, E., Potter, J.J., Rennie-Tankersley, L., Caballeria, J., Pares, A. (2004). “A randomized placebo controlled trial of vitamin E for alcoholic hepatitis” J Hepatol, 40(1): 40-6.
• San-Miguel, B., Alvarez, M., Culebras, J.M., González-Gallego, J., Tuñón, M.J. (2006). “N-Acetyl-cysteine protects liver from apoptotic death in an animal model of fulminant hepatic failure” Apoptosis, 11(11): 1945–57.
• Moreno, C., Langlet, P., Hittelet, A., Lasser, L., Degré, D., Evrard, S. et al. (2010). “Enteral nutrition with or without N-acetylcysteine in the treatment of severe acute alcoholic hepatitis: a randomized multicenter controlled trial” J Hepatol, 53(6): 1117–22.
• Phillips, M., Curtis, H., Portmann, B., Donaldson, N., Bomford, A., O’Grady, J. (2006). “Antioxidants versus corticosteroids in the treatment of severe alcoholic hepatitis-a randomised clinical trial” J Hepatol, 44(4): 784–90.
• Nguyen-Khac, E., Thevenot, T., Piquet, M.A., Benferhat, S., Goria, O., Chatelain, D. et al.(2011). “Glucocorticoids plus N-Acetylcysteine in Severe Alcoholic” Hepatitis N Engl J Med, 365(19): 1781-9.
• Mathurin, P., Lucey, M.R. (2012). “Management of alcoholic hepatitis” J Hepatol, 56(1): 39–45.
• Plauth, M., Cabré, E., Riggio, O., Assis-Camilo, M., Pirlich, M., Kondrup, J. et al. (2006). “ESPEN Guidelines on Enteral Nutrition: Liver disease” Clin Nutr, 25(2): 285-94.
• Puri, P., Thursz, M. (2016). “Intensive Enteral Nutrition in Alcoholic Hepatitis: More Food for Thought” Gastroenterology, 150(4), 803.
• Calvey, H., Davis, M.,Williams, R. (1985). “Controlled trial of nutritional supplementation with and without branched chain amino acids enrichment, in treatment of acute alcoholic hepatitis” J Hepatol, 1(2):141–51.
• Soberon, S., Pauley, M.P., Duplantier, R., Fan, A., Halsted, C.H. (1987).“Metabolic effects of enteral formula feeding in alcoholic hepatitis. Hepatology, 7(6): 1204–9.
• Cabre, E., Rodriguez-Iglesias, P., Caballeria, J., Quer, J.C., Sánchez-Lombraña, J.L., Parés, A. et al. (2000). “Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial” Hepatology, 32(1): 36–42.
• Mendenhall, C.L., Moritz, T.E., Roselle, G.A., Morgan, T.R., Nemchausky, B.A., Tamburro, C.H. et al.(1993).“A study of oral nutritional support with oxandrolone in malnourished patients with alcoholic hepatitis: results of a Department of Veterans Affairs cooperative study” Hepatology,17(4): 564–76.
• Alvarez, M.A., Cabre, E., Lorenzo-Zuniga, V. (2004). “Combining steroids with enteral nutrition: A better therapeutic strategy for severe alcoholic hepatitis? Results of a pilot study”, Eur J Gastroenterol Hepatol, 16(12): 1375–80.
• Schneeweiss, B., Pammer, J., Ratheiser, K., Schneider, B., Madl, C., Kramer, L. et al. (1993). “Energy metabolism in acute hepatic failure” Gastroenterology, 105(5): 1515–21.
• Plauth, M., Schuetz, T., (2009). Hepatology – Guidelines on Parenteral Nutrition Chapter 16. Ger Med Sci, 7: 1-12.
• Nasrallah, J.M., Galambos, J.T. (1980). “Amino acid therapy of alcoholic hepatitis” Lancet, 2(8207): 1276–7.
• Mezey, E.,Caballeria, J.,Mitchell, M.C., Parés, A., Herlong, H.F., Rodés, J. (1991). “Effect of parenteral amino acid supplementation on short-term and long-term outcomes in severe alcoholic hepatitis: a randomized controlled trial” Hepatology, 14(6): 1090–6.
• Bonkovsky, H.,Singh, R.H.,Jafri, I.C.H.,Fiellin, D.A., Smith, G.S., Simon, D. et al. (1991). “A randomized, controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. Short-term effects on nitrogen metabolism, metabolic balance, and nutrition” Am J Gastroenterol, 86(9): 1209–18.
• Augustina, S., Genesca, J. (2011). “Diagnostic and prognostic markers in liver cirrhosis” Dis Markers, 31(3): 119–20.
• Sonsuz, A. (2007). Patient Monitoring and Clinical Problems in Liver Cirrhosis. İ.Ü. Cerrahpaşa Tıp Fakültesi Sürekli Tıp Eğitimi Etkinlikleri Sempozyum Dizisi 58: 99-112.
• Cheung, K., Lee, S.S., Raman, M. (2012). “Prevalence and mechanisms of malnutrition in patients with advanced liver disease, and nutrition management strategies” Clin Gastroenterol Hepatol,10(2): 117-25.
• Tai, M.L., Goh, K.L., Mohd-Taib, S.H., Rampa, S., Mahadeva, S. (2010). “Anthropometric, biochemical and clinical assessment of malnutrition in Malaysian patients with advanced cirrhosis” Nutr J, 9(27): 1-7.
• Khan, R., Ahmed, A., Ismail, F.W., Abid, S., Awan, S., Shah, H., Hamid, S., Jafri, W. (2012). “Perception and knowledge about dietary intake in patients with liver cirrhosis and its relationship with the level of education” J Coll Physicians Surg Pak, 22(7): 435-9.
• Chadalavada, R., Biyyani, R.S., Maxwell, J., Mullen, K. (2010). “Nutrition in hepatic encephalopathy” Nutr Clin Pract, 25(3): 257-64.
• McClave, S.A., Martindale, R.G., Vanek, V.W., McCarthy, M., Roberts, P., Taylor, B. et al. (2009). “Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient” JPEN J Parenter Enteral Nutr, 33(3): 277-316.
• Suzuki, K.,Endo, J., Kohgo, Y., Ohtake, T., Ueno, Y., Kato, A. et al. (2012). “Guidelines on nutritional management in Japanese patients with liver cirrhosis from the perspective of preventing hepatocellular carcinoma” Hepatol Res, 42(7): 621–6.
• Mesejo, A., Juan, M., Serrano, A. (2008). “Liver cirrhosis and encephalopathy: clinical and metabolic consequences and nutritional support” Nutr Hosp, 23(2): 8-18.
• Yasutake, K., Bekki, M., Ichinose, M., Ikemoto, M., Fujino, T., Ryu, T. et al.(2012). “Assessing current nutritional status of patients with HCV-related liver cirrhosis in the compensated stage” Asia Pac J Clin Nutr, 21(3): 400-5.
• George, J., Ganesh, H.K., Acharya, S., Bandgar, T.R., Shivane, V., Karvat, A. et al. (2009). “Bone mineral density and disorders of mineral metabolism in chronic liver disease” World J Gastroenterol, 15(28): 3516-22.
• Katayama, K., Sakakibara, M., Imanaka, K., Ohkawa, K., Matsunaga, T., Naito, M. et al. (2011). “Effect of zinc supplementation in patients with type C liver cirrhosis” O J Gast, 1(2): 28-34.
• Chiba, M., Katayama, K., Takeda, R., Morita, R., Iwahashi, K., Onishi, Y. et al. (2013). “Diuretics aggravate zinc deficiency in patients with liver cirrhosis by increasing zinc excretion in urine”, Hepatol Res, 43(4): 365-73.
• Masuda, T., Shirabe, K., Yoshiya, S., Matono, R., Morita, K., Hashimoto, N. (2013). “Nutrition Support and Infections Associated With Hepatic Resection and Liver Transplantation in Patients With Chronic Liver Disease” JPEN J Parenter Enteral Nutr, 37(3): 318-26.
• Holecek, M. (2010). “Three targets of branched-chain amino acid supplementation in the treatment of liver disease” Nutrition, 26(5): 482–90.
• Yatsuhashi, H., Ohnishi, Y., Nakayama, S., Iwase, H., Nakamura, T., Imawari, M. (2011). “Anti-hypoalbuminemic effect of branched-chain amino acid granules in patients with liver cirrhosis is independent of dietary energy and protein intake” Hepatol Res, 41(11): 1027-35.
• Koreeda, C., Seki, T., Okazaki, K., Ha-Kawa, S.K., Sawada, S. (2011). “Effects of late evening snack including branched-chain amino acid on the function of hepatic parenchymal cells in patients with liver cirrhosis” Hepatol Res, 41(5): 417–22.
• Okumura, H., Nakamura, T., Miyake, H., Takeuchi, H., Katayama, T., Morine, Y. (2010). “Effect of long-term late-evening snack on health-related quality of life in cirrhotic patients” Hepatol Res, 40(5): 470–6.
• Hidaka, H., Nakazawa, T., Kutsukake, S., Yamazaki, Y., Aoki, I., Nakano, S. (2013). “The efficacy of nocturnal administration of branched-chain amino acid granules to improve quality of life in patients with cirrhosis”J Gastroenterol, 48(2): 269-76.
• Nakaya, Y., Okita, K., Suzuki, K., Moriwaki, H., Kato, A., Miwa, Y. et al. (2007). “BCAA-enriched snack improves nutritional state of cirrhosis” Nutrition, 23(2): 113–20.
• Itou, M., Kawaguchi, T., Taniguchi, E., Shiraishi, S., Ibi, R., Mutou, M. et al. (2009). “Heating improves poor compliance with branched chain amino acid-rich supplementation in patients with liver cirrhosis: A before-after pilot study” Mol Med Report, 2(6): 983-7.
• Malaguarnera, M., Risino, C., Cammalleri, L., Malaguarnera, L., Astuto, M., Vecchio, I. et al. (2009). “Branched chain amino acids supplemented with L-acetylcarnitine versus BCAA treatment in hepatic coma: a randomized and controlled double blind study” Eur J Gastroenterol Hepatol, 21(7): 762–70.
• Hayashi, M., Ikezawa, K., Ono, A., Okabayashi, S., Hayashi, Y., Shimizu, S. et al. (2007). “Evaluation of the effects of combination therapy with branched-chain amino acid and zinc supplements on nitrogen metabolism in liver cirrhosis” Hepatol Res, 37(8): 615-9.
• Ishikawa, T. (2012). “Early administration of branched-chain amino acid granules” World J Gastroenterol, 18(33): 4486-90.
• Hayaishi, S., Chung, H., Kudo, M., Ishikawa, E., Takita, M., Ueda, T. (2011). “Oral branched-chain amino acid granules reduce the incidence of hepatocellular carcinoma and improve event-free survival in patients with liver cirrhosis” Dig Dis, 29(3): 326-32.
• Peng, S., Plank, L.D., McCall, J.L., Gillanders, L.K., McIlroy, K., Gane, E.J. (2007). “Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study1–3” Am J Clin Nutr, 85(5): 1257–66.
• Tsien, C.D., McCullough, A.J., Dasarathy, S. (2012). “Late evening snack: Exploiting a period of anabolic opportunity in cirrhosis” J of Gastro Hepatol, 27(3): 430-41.
• Plank, L.D., Gane, E.J., Peng, S., Muthu, C., Mathur, S., Gillanders, L. et al. (2008). “Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial” Hepatology, 48(2): 557-66.
• Kawaguchi, T., Taniguchi, E., Itou, M., Mutou, M., Ibi, R., Shiraishi, S. et al. (2008). “Supplement improves nutrition and stresses caused by examination-associated fasting in patients with liver cirrhosis” Hepatol Res, 38(12): 1178-85.
• Sharon Tai, M.L., Razlan, H., Goh, K.L., Mohd Taibc, S.H., Mohd Huzainic, A.H., Rampal, S. et al.(2011). “ Short term nasogastric versus oral feeding in hospitalised patients with advanced cirrhosis: A randomised trial” the European e-Journal of Clinical Nutrition and Metabolism, 6(6): 242-7.
• Sorrentino, P., Castaldo, G,. Tarantino, L., Bracigliano, A., Perrella, A., Perrella, O. et al. (2012). “Preservation of nutritional-status in patients with refractory ascites due to hepatic cirrhosis who are undergoing repeated paracentesis” J GastroenterolHepatol, 27(4): 813-82.
• Yamanel, L. (2008). “Hepatic Encephalopathy” Yoğun Bakım Dergisi, 8: 111-20.
• Ünsal, B. (2012). “Importance of Nutrition in Minimal Hepatic Encephalopathy” Güncel Gastroenteroloji, 16: 163-5.
• James, J.H. (2002). “Branched chain amino acids in hepatic encephalopathy” Am J Surg, 183(4): 424-9.
• Morgan, T.R., Moritz, T.E., Mendenhall, C.L. (1995). “Protein consumption and hepatic encephalopathy in alcoholic hepatitis” J Am Coll Nutr, 14(2): 152-8.
• Özcan, P., Tuğrul, S. (2011). “Nutrition In Special Cases” Klinik Gelişim, 24: 53-8.
• Karakan, T. (2010). “Nutritional Support In Chronic Liver Disease” İç Hastalıkları Dergisi, 7: 233-7.
• Akın, P., Erden, B. (2002). “Hepatic Encephalopathy” Hepato- Bilier Sistem ve Pankreas Hastalıkları Sempozyum Dizisi, 28: 120.
• Les, I., Doval, E., García-Martínez, R., Planas, M., Planas, M., Cárdenas, G., Gómez, P. et al. (2011). “Effects of branched-chain aminoacids supplementation in patients with cirrhosis and a previous episode of hepatic encephalopathy: a randomized study” Am J Gastroenterol, 106(6): 1081-8.
• Als-Nielsen, B., Koretz, R.L., Kjaergard, L.L., Gluud, C. (2003). “Branched-chain amino acids for hepatic encephalopathy”, Cochrane Database Syst Rev, (2): CD00193.
• Kircheis, G., Nilius, R., Held, C., Berndt ,H., Buchner, M., Görtelmeyer, R. et al. (1997). “Therapeutic efficacy of L-ornithine-L-aspartate infusions in patients with cirrhosis and hepatic encephalopathy: Results of a placebo-controlled, double-blind study” Hepatology, 25(6): 1351-60.
• Stauch, S., Kircheis, G., Adler, G., Beckh, K., Ditschuneit, H., Görtelmeyer, R. et al. (1998). “Oral L-ornithine-L-aspartate therapy of chronic hepatic encephalopathy: Results of a placebo-controlled double-blind study” J Hepatol, 28(5): 856-64.
• Abid, S., Jafri, W., Mumtaz, K., Islam, A., Abbas, Z., Ali Shah, H., Hamid, S. (2010). “Efficacy of L-ornithine-L-aspartate as an adjuvant therapy in cirrhotic patients with hepatic encephalopathy”, J Coll Physicians Surg Pak, 21(11): 666-71.