Diet and nutritional care for DDLT: A case study

V. Karthiga

Dietitian, Kauvery Hospital, Hosur

Background

A 57-years old female was admitted for DDLT. Relevant investigations were done. Covid-19 RT-PCR was negative pre-operatively. After anaesthetic clearance, cardiologist opinion and written informed consent, she underwent DDLT on 22/10/2022.

After the procedure patient was shifted to the transplant ICU for post-operative care. The patient was extubated on POD-1 and connected to HFNC (4-5lit O2). 1 unit LD PRBC, and 1 unit FFP were transfused and started the oral diet on the same day.

The study and overview of the diet and Nutritional care till the discharge of the patient is presented

Liver function test

Below are the values of Liver Function Tests carried out during the hospitalization period of the patient

	21-Oct	22-Oct	23-Oct	24-Oct	25-Oct	26-Oct	27-Oct	28-Oct	29-Oct	30-Oct	31-Oct	01-Nov
Bilirubin total	2.9	2.9	2.2	2	1.7	1.7	2.1	1.7	2.1	1.7	1.7	1.7
Bilirubin direct	2	2	1.7	1.4	1.2	1.2	1.3	1	1	1.2	0.8	1
Bilirubin indirect	0.9	0.9	0.5	0.6	0.5	0.5	0.8	0.7	0.7	0.5	0.8	0.5
Total protein	4.8	4.8	5.3	2.2	5	5	4.8	4.7	5.2	4.8	4.8	5.2
Serum albumin	2.4	2.4	2.8	2.5	2.8	2.7	2.9	2.8	2.8	2.7	2.9	2.5
Serum globulin	2.4	2.4	2.5	2.7	2.2	2.1	2.1	1.8	2.4	2.4	2.1	2.7
SGOT(ALT)	60	63	59	52	47	45	46	42	39	37	35	38
SGPT(AST)	97.2	97.2	87.3	90	87	83	79	72	74	69	64	59

Clinical data

Presentation: DCLD-Decompensated chronic liver disease (HbsAg related) with Portal Hypertension

Diagnosis: CLD/ PHT/ CHILD C/ HEP.B RELATED (MELD – 29)

History of past illness: Known case of Systemic hypertension 18 years on treatment

Plan of Treatment: DDLT

Physical Findings: No identified edema, Appetite Normal, No identified chewing, swallowing difficulties, Bowel movements good.

Medications

Below are the medications provided during the hospitalization period

S.No	Drug name	Strength	Frequency			Route	Relationship with meal
			M	A	N
1	Tab. Pan	40 mg	1	0	0	Oral	Before food
2	Tab. Tafnat	25 mg	0	1	0	Oral	After food
3	Tab. Neurobion forte		0	1	0	Oral	After food
4	Tab. Vitamin D	60 k	once a week			Oral	After food
5	Tab. Acyclovir	400 mg	1	0	1	Oral	After food
6	Tab. Forcan	200 mg	0	0	0	Oral	After food
7	Tab. Ecosprin	75 mg	0	1	0	Oral	After food
8	Tab. Calcimax	500 mg	1	0	1	Oral	After food
9	Syp. Duphalac	20 ml	0	0	20ml	Oral	After food
10	Resource power	3 scoop	1	1	1	Oral	After food
11	Refresh eye drop	2 drops	2	2	2	Oral	After food
12	Cap. Katadol	100 mg	SOS
Immuno suppression drugs
1	Tab. Prograf	2 mg	1	0	1	Oral	Before food
2	Tab. Mycept	500 mg	1	0	1	Oral	After food
3	Tab. Wysolone	20 mg	1	0	0	Oral	After food

Vitals

Below are reports of the vitals observed during the course of hospitalization

Dietary Guidelines

Diet and nutrition after your liver transplant

After liver transplant, one may need to adjust the diet to keep liver healthy and functioning well and to prevent excessive weight gain. The patient should maintain a healthy weight, which can help prevent infections, high blood pressure and other complications. The nutrition specialist (dietitian) and other members of the medical treatment team will work to create a healthy-eating plan that meets the needs and complements of patientâ€™s lifestyle.

The role of dietitian is to provide the patient with healthy food options and ideas to use in patients eating plan. The recommendations include: Eating at least five servings of fruits and vegetables each day

Eating lean meats, poultry and fish
Eating whole-grain breads and cereals and other grains
Having enough fibre in your daily diet
Drinking low-fat milk or eating other low-fat dairy products, to help maintain enough calcium
Maintaining a low-salt and low-fat diet
Following food safety guidelines
Staying hydrated by drinking adequate water and other fluids each day
Drinking about 2 litres of fluid every day. This is good for the kidney and help remove waste products from the body. Bottled mineral water, herbal teas, pasteurised low-fat milk, and fruit juices are good.
Avoiding alcohol
Avoiding grapefruit and grapefruit juice due to its effect on a group of immunosuppression medications (calcineurin inhibitors)
Avoiding raw or uncooked seafood
Avoiding raw or rare cooked meat and other non-vegetarian food.
Avoiding undercooked eggs
Avoiding milk and dairy products that are unpasteurized
Avoiding legumes like bean and alfalfa sprouts
Avoid sugary snacks such as cakes and biscuits between meals. If hungry, should eat some fruit or vegetables (low in calories).
Using salt sparingly when cooking
Trying not to add salt to cooked food or salad
Avoiding salty foods, eg potato crisps, pickles and tinned food

Further recommendations:

Measure body weight every day
Always wash and peel fresh fruit
Vegetables that grown in soil, example – potatoes, should always be peeled and cooked in boiling water. Cooking vegetables in a pressure cooker is a good way of saving the vitamin content. Should not eat raw vegetables, example cucumber.
Should not recommend cheese made from unpasteurised milk and avoid cheeses with mould.
Recommend to buy small amounts of dairy products at one time, so that patient eat fresh.

Nutritional Prescription

Initial Prescription

Energy: 1500 Kcal

Protein : 71.7g @1.2g/Kg IBW

CHO: 60% of Total Calories

Fat: 20% of Total Calories

Salt: 2g/day

micronutrients: as per RDA

Target nutritional values Fixed Post Surgery

Energy: 1800 Kcal

Protein : 88.5g @1.5g/Kg IBW

CHO: 60% of Total Calories

Fat: 20% of Total Calories

Salt: 2g/day

micronutrients: as per RDA

Oral Nutritional supplements are also prescribed as a part of Nutritional Support

Medical Nutritional Therapy Post OP

Energy: To provide an adequate amount of energy to post-surgery requirements and to maintain optimal nutritional status. A small frequent meal (6 meals) is recommended for effective absorption of nutrition. Weight management is also necessary as obesity can complicate the underlying medical condition.

Carbohydrates: Carbohydrate intake supports the elevated energy needs associated with post-surgical metabolic alterations and wound healing.

Protein: Protein intake provides the amino acids required to support wound healing, immune function and muscle preservation.

Fat: To provide a moderate amount of fat preventing unhealthy weight gain, medium-chain triglycerides are recommended as they are easily absorbable.

Micronutrients: Micronutrient supplements are necessary to compensate losses. Vitamin B12 and calcium supplements are recommended.

Diet history

Below was the diet followed during the Hospitalization

Diet History
Hospital Recall
Day	Date	Types of Diet	Energy (Kcal)	Protein (g)	Remarks
1	21-10-22	NPO	0	0	Pre-Operative
2	22-10-22	NPO	0	0	Procedure Done DDLT
3	23-10-22	CLD Liquid Diet	124	2.2	Initiated with sips of water and clear liquid Diet
4	24-10-22	LD + soft solid Diet	248	7.8	Diet Modified to soft solid diet
5	25-10-22	Liquid Diet	327	8.7	Diet Modified to Liquid since the patient had complications of fever and vomiting and persistent nausea. Mild abdominal disension also noted
6	26-10-22	Normal Protien Soft SOlid Diet	528	20	GI symptoms reduced, diet modified to normal protein soft solid diet
7	27-10-22	High Protein Diet	655	27	Diet modified to High protein diet, patient apetite was good. No abdominal discomfort
8	28-10-22	High Protein Diet	947	63	Oral Intake Good
9	29-10-22	High Protein Diet	1030	67	Oral Intake Good
10	30-10-22	High Protein Diet	1009	73	Oral Intake Good
11	31-10-22	High Protein Diet	1032	80	Oral Intake Good
12	01-11-22	High Protein Diet	1131	83.4	Oral Intake Good

Achievements

- Target Nutrients achieved 80% of energy and 100% of Protein targeted
- Discharge Diet Advise given (Patient discharged on 02/11/2022).

a.Salt restricted High Protein Diet

Diet and nutritional care for DDLT: A case study