Terapi NutrisiTerapi Nutrisipadapada

Penyakit Hati KronikPenyakit Hati Kronik

Dani RosdianaDani RosdianaBagian Penyakit DalamBagian Penyakit Dalam

FK UNRI Pekanbaru/ RS Arifin AhmadFK UNRI Pekanbaru/ RS Arifin Ahmad

Hati memegang peran sentralHati memegang peran sentral

Metabolisme tubuhGangguan faal hati berat, misal Sirosis hati sudah disertai kapilarisasi sinusoid

Metabolisme pasti terganggu

* CLD / Liver Cirrhosis: chronic inflammation, esp. in advanced stage liver cells injury functi- onal failure nutrient metabolism disturbances malnutrition morbidity and mortality

* The liver: plays a central and fundamental role of nutrition and body nutrient metabolism

Faktor penyebab malnutrisi pada penyakit hati kronik

• Asupan kurang• Gangguan metabolisme dan penyimpanan• Gangguan sintesis• Malabsorpsi dan maldigesti• Pengaruh terapi : Neomisin Laktulosa Diuretika Kolistiramin

ChronicLiver

DiseasesReduced Net

Nutrient Intake

Metabolicdisturbances Malnutrition

(P.E.M)

MorbidityMortality

The interplay of the factors influencing the progression or regression of Chronic Liver Diseases and Malnutrition

Malnutrition (PEM) in Chronic Liver Diseases

* PEM is common in CLD and positively correlated with functional severity of liver injury. * Prevalences of PEM were similar in alcoholic and non-alcoholic LC

* PEM present in 20% of well-compensated LC pts. and more than 60% severe LC pts. (Italian Multicentre Cooperative Project on Nutrition in LC. 1994)

(ESPEN consensus, 1997)

Malnutrition (PEM) in Chronic Liver Diseases

0

10

20

30

40

Child-Pugh AChild-Pugh BChild-Pugh C

TSF < 5th %(triceps skinfold)

MAMC < 5th % (midarm muscle circumference)

The proportion of severe malnutrition of Liver Cirrhotic patients in the three Child-Pugh classes. (n= 120)

(Caregaro et al, 1996)

a. GI disturbances: - low intake, anorexia, nausea, vomit, dyspepsia - malabsorbsion, steatorrhea, diarrhea b. Metabolic changes: - liver failure, hormonal changes, hypermetabolic, - nutrient deficiencies (low intake & storage), etc c. Complications of LC: - infections, GI bleeding, encephalopathy, etc d. Management of LC: - fasting (surgery), false diet, antibiotics, etc.

Malnutrition (PEM) in Chronic Liver Diseases

The etiology of PEM is multifactorial:

Asesmen klinik, malnutrisi pd Penyakit hati kronik

Didasarkan pada : Riwayat penyakit Riwayat gizi Pemeriksaan fisik Laboratorium

Pemeriksaan penunjang

BMI : sulit diinterpretasi Asites Edema

Skin-fold thicknessArm muscle circumference

Pemeriksaan laboratorium :

RutinHepatic secretory protein Albumin Transferin

Subjective global assesment

Riwayat penyakit

• Perubahan berat badan• Perubahan asupan makanan• Keluhan gastrointestinal• Kapasitas fungsional• Penyakit / keadaan yang dapat dicurigai sebagai penyebab

Subjective global assessment

Pemeriksaan fisik

• Lemak subkutan• Muscle wasting• Edema pretibia / anasarca• Asites

* Nutritional support may improve - nutritional status, - liver functions & regeneration, - body regeneration, - short-term and long-term prognosis. * Nutritional therapy should be included in the management of LC pts., consist of - oral dietetics, - enteral nutrition, - parenteral nutrition.Dr. F. Soemanto PM., 2001

Kebutuhan nutrisi pasien penyakit hati kronik berat

Malnutrisikalori-proteinHiperkatabolik

• Tinggi kalori dan tinggi protein• Kalori basal dan tinggi protein• Tinggi kalori dan protein standar

A. Kebutuhan Kalori* Stable LC: 35 - 40 kcal/kgBW/day Unstable LC, w/ complication: 40 - 45 kcal

* Carbohydrate and Lipid (30-35% total calorie)

Pertimbangan

• Sering dengan P-S shunting• Tinggi protein memacu ensefalopati • Sering intoleransi

Tinggi kalori danprotein standar

Tinggi kalori = 1,5 kali basal

B. Protein

Malnutrisi protein-kaloriBelum pernah ensefalopati 1,5 gram/Kg BB

Ensefalopati kronikMalnutrisi protein-kalori BCAA

* Stable LC: 1.0 - 1.2 g/kgBW/day (60-80 g/day) * LC w/ hypoalbumin/edema/ascites: 1.5 g/kgBW/day

* LC w/ encephalopathy: 0.6 g/kgBW/day plus BCAA step by step increasing to normal intake

C. LemakKeuntungan

Kalori tinggi dalam vol sama Tidak memacu insulin/metabolic rate Mengatasi defisiensi asam lemak esensial Rasanya enak

Kerugiannya :

steatorrhe, steatosis / over feeding

Dapat sampai 45%

D. Mineral dan trace elementD. Mineral dan trace element

Diit rendah garam Hiponatremia ringan bukan CI diit rendah garam

Asites dan edema akibatreabsorpsi air dan garam

Kadar Na absolut tinggi

* LC w/ edema, ascites: fluid & Na+ restriction Fluid: 0.5 - 1.5 L/day, Na+: 500 - 2000 mg/day

Nutrisi parenteral

Tujuan : nutrisi tambahan bukan nutrisi parenteral total (TPN)

Indikasi TPN : - Iskhemia usus - IBD berat - Fistula enterokutan - Divertikulitis berat - Mukositis berat - Pasca reseksi usus - Obstruksi SC

Prinsip nutrisi parenteral

• Dapat mencegah hiperkatabolik• Glukosa tunggal bukan pilihan tepat• BCAA ? Biasanya kadarnya menurun• perhatikan volue karena asites dan edema

Lemak dapat digunakan hanya harus hati-hatiBerbasis asam amino