Transcript Presentation Title
Fluid and Electrolytes Alterations and Liver Failure
Heidi Monroe MS, RN, CNS, CCTN
CNS/Educator Organ Transplant Unit University of Colorado Hospital [email protected]
Dallas, TX • November 2–4, 2012
About Me
Dallas, TX • November 2–4, 2012
How Do You Manage Fluid & Electrolytes in Liver Failure?
THE BEST YOU CAN!
Dallas, TX • November 2–4, 2012
Normal Liver Hepatic vein Sinusoid Portal vein Liver Coronary vein Splenic vein Dallas, TX • November 2–4, 2012
Functions of the Liver
• Detoxifies blood • Stores glycogen • Protein synthesis (albumin) • Digestion (bile production / fat emulsification) • Carbohydrate metabolism • Platelet synthesis
Dallas, TX • November 2–4, 2012
Cirrhosis
• Definition: (
irreversible)
scaring of the liver • Diagnosed with biopsy • 7 th leading cause of death for adults aged 25-64 (Hansen 2010) • 16,758 patients awaiting liver transplant in US (unos.org 8-23-12)
Dallas, TX • November 2–4, 2012
Diseases Causing Liver Failure
UNOS 8-23-12
Dallas, TX • November 2–4, 2012
Cirrhotic Liver Distorted sinusoidal architecture leads to increased resistance Portal vein Portal systemic collaterals Splenomegaly Dallas, TX • November 2–4, 2012
Cirrhotic Liver
Dallas, TX • November 2–4, 2012
What Does Cirrhosis Look Like?
Dallas, TX • November 2–4, 2012
Complications of ESLD (Decompensated Cirrhosis)
• Portal Hypertension • GI Bleed / Varices • Ascites • Systemic Bacterial Peritonitis (SBP) • Hepatorenal Syndrome • Hyponatremia • Encephalopathy
Dallas, TX • November 2–4, 2012
Cirrhotic Liver Distorted sinusoidal architecture leads to increased resistance Portal vein Portal systemic collaterals Splenomegaly Dallas, TX • November 2–4, 2012
ESLD Catch 22
Portal HTN Portal Pressure Vasodilation of Splenic Vessels Varices Systemic BP Systemic Vasodilation SVR Nitric Oxide Released
Dallas, TX • November 2–4, 2012
Varices
Dilated sub-mucosal veins that develop in the esophagus as a result of portal hypertension
Dallas, TX • November 2–4, 2012
Variceal Growth Over Time
NO varices SMALL varices LARGE varices Dallas, TX • November 2–4, 2012
Variceal Hemorrhage
• Predictors of hemorrhage: • Variceal size • Red signs • Child B/C (measure of disease severity) • Treatment: • Terlipressin effective treatment (Loannou 2009)
Dallas, TX • November 2–4, 2012
N Engl J Med 1988; 319:983
Endoscopic Variceal Band Ligation
• Laine (1995) forced the movement to banding • Bleeding controlled in 90% • Rebleeding in 30% • Band ligation with vasoactive drugs proven superior for treatment of active bleed (D’ Amico 2010) • Monitor PT/PTT/INR/PLT/H&H
Dallas, TX • November 2–4, 2012
Banding vs Beta-blockers
• Gluud 2012 – meta-analysis • Banding vs Beta-blockers to prevent GI bleed with ESLD – Banding reduced number of GI Bleeds – No difference in bleeding related mortality • Cannot rule out benefit of beta-blocker – Interventions for bleeding risk patients only
Dallas, TX • November 2–4, 2012
Ascites SVR BP Kidneys retain Ascites Na+/H2O
• Low albumin is factor in third spacing • Ascites is a Na+ issue – water follows salt!
• Na+ restriction is key
Dallas, TX • November 2–4, 2012
Ultrasound is the Most Sensitive Method to Detect Ascites
Ascites Liver Dallas, TX • November 2–4, 2012
Ascites
• 60% of cirrhotics will develop • Poor prognosis • Treatment Grade I Grade 2 Grade 3 Elsevier (2010) Mild No Treatment Moderate Large Na+ Restriction Diuretics Paracentesis Na+ Restriction ?Albumin
Diuretics (not Refractory)
Dallas, TX • November 2–4, 2012
What is a Low Salt Diet?
WHATEVER THE PATIENT BELIEVES IT IS!
Dallas, TX • November 2–4, 2012
Refractory Ascites
• Not responsive to diuretics • Requires frequent paracenteses – Albumin infusions post reduces morbidity and mortality (Bernardi 2012) • Can lead to Hepatorenal Syndrome (HRS) • High mortality • Requires transplant (if candidate)
Dallas, TX • November 2–4, 2012
Systemic Bacterial Peritonitis SBP
• Infection of membrane lining abdominal cavity (ascites fluid) • ESLD condition worsens? Always rule out SBP!
• Life threatening – treat ASAP • No specific antibiotic of choice (Chavez-Tapia 2009)
Dallas, TX • November 2–4, 2012
Hepatorenal Syndrome (HRS)
• Advanced ESLD • Type I: – Rapidly progressing decrease in GFR – Increased BUN, Cr – Oliguria – Extreme hyponatremia and hyperkalemia • Type II: – Steady decline in GFR – BUN, Cr slowly increase with disease progression • Grim prognosis -10% survive 6 months (Gonwa, 2006) • Treatment: – Stop diuretics / nephrotoxic medications, albumin infusions if >5L ascites removed, systemic vasoconstrictors, TIPS, RRT, liver transplant (may need a liver and kidney)
Dallas, TX • November 2–4, 2012
Hyponatremia
• Goes along with HRS • Predictor of early mortality if Na+<130 (Moini 2011) • As kidney function worsens, extra fluid retention dilutes the retained Na+ • Treatment – Liver Transplant (proven), fluid restriction – Under investigation: vasoconstrictors, TIPS, albumin, dialysis – Fluid restriction for serum Na+ <120 – Not effective: dialysis
Dallas, TX • November 2–4, 2012
TIPS
• Transjugular Intrahepatic Porto-systemic Shunt (TIPS) • Uncontrolled GI Bleeding • Benefits: – Improve renal function – My increase survival – Potential to stop dialysis (still retain Na+) • Risks: – Worsen Encephalopathy – Delayed recovery from TIPS – Worsen liver failure (not candidate if very late ESLD)
Dallas, TX • November 2–4, 2012
Hepatic Encephalopathy Pathogenesis
Failure to metabolize NH 3 NH 3 Shunting Bacterial action Protein load Toxins GABA-BD receptors Dallas, TX • November 2–4, 2012
Encephalopathy
• Definition • Incidence: affects 30-70% of cirrhotics • Stages I(mild) – IV(coma) • Treatment: – Find cause – Lactulose – 3BMs/day – monitor fluid/electrolytes (Na+, K+, HC03) – NOT need to check Ammonia level
Dallas, TX • November 2–4, 2012
Encephalopathy Precipitants
• Infection / fever • Excess protein • GI Bleed • Narcotics / sedatives / sleep agents • TIPS • Diuretics (low serum K+, low volume)
Dallas, TX • November 2–4, 2012
Malnutrition
• Affects up to 80% of cirrhotics (Tsiaousi 2008) • Higher morbidity and mortality • Causes: – Loss of appetite (cytokines) / poor intake / altered taste – Restricted stomach’s ability to expand (ascites) – Functional dyspepsia – Impaired digestion/absorption (portal HTN) – Altered nutrient metabolism – Cholestatic liver = reduced bile salt concentration = steatorrhea – Hyper metabolic state – Loss of protein synthesis in liver – Hyperinsulinemia
Dallas, TX • November 2–4, 2012
Malnutrition
• Early intervention is key – Assessment: • Severity of liver disease • Malnutrition severity – diagnosed by Dietician • Dietary goals: (maintain body weight) – Avoid Alcohol and excess fat – 4-7 meals a day (with carbs and proteins) – Avoid long periods of NPO in hospital – Enteral nutrition (when severe) – TPN secondary option • BCAA formula favorable for protein intolerant • Correct vitamin/mineral deficiency if needed
Dallas, TX • November 2–4, 2012
MELD Score?
•
M
odel for
E
nd Stage
L
iver
D
isease (
MELD
) • Predictor of mortality • Serum Cr, Bilirubin, INR • Range: 6-40 • Exceptions – cancer, re-transplant • The higher the MELD, the sicker the patient, closer to transplant (www.unos.org)
Dallas, TX • November 2–4, 2012
Major Electrolytes to Monitor in ESLD
• •
Na+ K+
• Mg+ • Phos+ • Other labs: – WBC – infection – H&H bleeding/dehydration – PT/INR – PLT – they will be low, watch for bleeding!
– Albumin – Chemistry – renal function – Cancer indicators (AFP, CEA, CA19-9)
Dallas, TX • November 2–4, 2012
Thank You!
Questions?
Dallas, TX • November 2–4, 2012
Acknowledgements
• Jay Burton, MD – Hepatology Attending at UCH / Medical Director for the Medicine Specialties Unit. Authorized the use of all photos used in this presentation.
• Special thanks to the many amazing ESLD patients that I have had the pleasure of caring for.
Dallas, TX • November 2–4, 2012
Questions?
Dallas, TX • November 2–4, 2012
References
• • • • • Alessandria C , Elia C , Mezzabotta L , Risso A , Andrealli A , Spandre M , Morgando A , Marzano A , Rizzetto M . (2011). Prevention of paracentesis-induced circulatory dysfunction in cirrhosis: Standard vs half albumin doses. A prospective, randomized, unblended pilot study. Digestive and Liver Disease, Nov; 43(11): 881-6.
Assadi, F. (2012). Hyponatremia: A problem-solving approach to clinical cases. Journal of Nephrology, Jan 30:0. doi: 10.5301/jn.5000060.
Barnardi, M., Caraceni, P., Navickis, RJ., Wilkes, MM. (2012). Albumin infusion in patients undergoing large-volume paracentesis: A meta-analysis of randomized trials. Hepatology, 55(4): 1172-81.
Buttaro, T., Trybulski, J., Baily, P. P., Sandberg-Cook, J. (2008). Primary care: A collaborative practice 3rd Edition. St. Louis, Missouri: Mosby Elsevier Inc.
Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD002232. DOI: 10.1002/14651858.CD002232.pub2.
Dallas, TX • November 2–4, 2012
References
• • • • • D'Amico G, Pagliaro L, Pietrosi G, Tarantino I. Emergency sclerotherapy versus vasoactive drugs for bleeding esophageal varices in cirrhotic patients. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD002233. DOI: 10.1002/14651858.CD002233.pub2.
Fleming, J., & Abbass, A. (2010). Hepatorenal syndrome: A comprehensive overview for the critical care nurse. Critical Care Nursing Clinics of North America, 22(3), 351-368.
Garcia-Tsao, G. & Lim, JK. (2009). Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. American Journal of Gastroenterology, July 104(7): 1802-29.
Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in esophageal varices in adults. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD004544. DOI: 10.1002/14651858.CD004544.pub2.
Hansen, L., Sasaki, A., Zucker, B. (2010). End-stage liver disease: Challenges and practice implications. The Nursing Clinics of North America, Sep 45(3): 411-26.
Dallas, TX • November 2–4, 2012
References
• • • • • • • Kashani A., Landaverde, C., Medici, V., Rossaro, L. (2008). Fluid retention in cirrhosis: Pathophysiology and management. QJM, 101(2): 71-85.
Laine, L. (1995), Ligation: Endoscopic treatment of choice for patients with bleeding esophageal varices?. Hepatology, 22: 663 –665. Moini M , Hoseini-Asl MK , Taghavi SA , Sagheb MM , Nikeghbalian S , Salahi H , Bahador A 25(4): 638-45. , Motazedian M , Jafari P , Malek-Hosseini SA . (2011). Hyponatremia a valuable predictor of early mortality in patients with cirrhosis listed for liver transplantation. Clinical Transplantation, Runyon, B. (2009). Management of adult patients with ascites due to cirrhosis: An update. Hepatology, 49(6), 2087-2107.
Singhal S 32. , Baikati KK , Jabbour II , Anand S . (2012). Management of refractory ascites. American Journal of Therapeutics, Mar; 19(2): 121 Tsiaousi, E., Hatzitolios, A, Trygonis, S., Savopoulos, C. (2008). Malnutrition in end stage liver disease: Recommendations and nutritional support. Journal of Gastroenterology and Hepatology, 23(4), 527-533.
Zhao, V., & Ziegler, T. (2010). Nutrition support in end stageliver disease. Critical Care Nursing Clinics of North America, 22(3), 1-12.