4.8.1 Nutritional status pre-transplant

There have been several studies assessing the nutritional status of patients and the impact on outcomes prior to liver transplantation [6]. Malnutrition leads to increased operative blood loss, longer hospital stay in the intensive care unit (ICU), prolonged ventilator support requirements and higher risk of mortality. Figueiredo et al. found that longer ICU stay was associated with lower handgrip strength and lower aromatic amino acid concentrations. Low intakes of branched chained amino acids (BCAA) were associated with longer total hospital stay and increased infection rates. They did not find any association with mortality and nutritional status [7]. Dick et al. found that underweight patients required more dialysis, had a higher rate of combined liver-kidney transplantation and higher retransplantation rates due to graft failure and were more likely to die from haemorrhagic complications or cerebrovascular accidents. They also found that being underweight was a significant predictor of risk to survival [8].

Although undernutrition is common amongst liver transplant recipients, studies show that pretransplant nutritional supplementation does not have a major effect on patient outcome and regular dietetic support may be as effective at increasing energy intake as nutritional supplementation [9]. Studies show that Body Mass Index (BMI) corrected for ascites and other fluid disturbances is not independently predictive of patient or graft survival [10]. It has been noted that nutritional status does not influence graft or patient survival rates, incidence of infection or rejection, but severely undernourished patients have longer ICU stays compared to well-nourished patients [11].

Overweight and obese patients have increased rates of wound infection and multisystem organ failure. Patients with morbid obesity (BMI >40) are associated with significant decreases in patient and graft survival as well as increased 30-day mortality. Cardiovascular mortality and infection-related allograft failure are associated with BMI >35 [12]. The 5-year mortality rate is significantly higher in the severely obese and morbidly obese [13,14].

4.8.2 Nutritional requirements and feeding immediately post transplant

With the exception of the Roux-en-Y hepaticojejunostomy, it is recommended that normal food and/or enteral nutrition (EN) be commenced within 12–14 h post surgery [15]. Transplant patients who received early EN had fewer viral infections and had better nitrogen retention. Although evidence is limited, EN is usually delayed between 3–5 days post Roux-en-Y liver transplant as there are risks of leaks and biliary obstructions and there has been some manipulation to the small intestine. The technique involves a loop of small intestine 10–20 cm distal to the ligament of Treitz being divided and brought up to the donor bile duct. An end-to-side anastomosis is then completed between the two. It is the preferred technique when the donor bile duct diameter is small (paediatric, split liver and living donor transplants) and in patients with extrahepatic biliary disease (e.g. primary sclerosing cholangitis).

In the immediate phase post transplant, protein catabolism is significantly increased as demonstrated by the excretion of large amounts of urinary nitrogen [2,6]. Catabolism occurs due to the release of catabolic hormones promoted by surgery and corticosteroids. Due to the elevated nitrogen excretion, a protein intake of 1.2–1.5 g/kg/day is recommended [15]. BCAAs remain an area of interest pre and post tranplantation. Studies have shown that liver transplantation rapidly normalises aromatic acid clearance and that BCAAs increase above normal and there is little need for specialised amino acids formulations post transplant [16]. Other studies have shown non-significant improvements in patients who received immuno-nutrition compared to patients who received standard nutrition. Therefore, more studies are needed to justify their use [2].

Energy requirements are not significantly elevated in the uncomplicated patient after transplant but these patients still require additional energy due to the reasons explained above [17]. Therefore it is recommended that patients receive an energy intake of 35–40 kcal/kg/day [15].

Enteral nutrition should be continued until patients are able to maintain an adequate oral intake [18]. Electrolyte and mineral abnormalities are common and are usually related to abdominal drain, gastrointestinal losses and medications. Reduced concentrations of zinc affect oral intake due to decreased taste sensation. Nausea and early satiety secondary to gastroparesis, ascites, small intestinal dysmotility and undernutrition also contribute to reduced intake and should be monitored closely [19].

4.8.3 Metabolic syndrome post liver transplant

Metabolic complications such as diabetes, hypercholesterolaemia, obesity and hypertension are common after liver transplantation and contribute to patient morbidity and mortality [20]. Risk factors are shown in Box 4.8.2

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