Why is Nutritional Care Important?

1. To relieve the symptoms of end stage liver disease (ESLD) & to optimize preoperative nutritional status.

2. To provide appropriate nutrients postoperatively for promoting anabolism, wound healing & to prevent the longer intensive care unit, hospital stays & high costs of care.

3. To manage the nutritional side effects of immunosuppressive & other drugs.

4. To keep your blood sugar levels normal, by eating regular meals & snacks.
    

What is your Pre-Transplant Diet?
Many patients with severe liver disease have lost a significant amount of their body fat stores and body protein stores by the time they are referred to the liver transplant unit.
Diet must be high energy/high protein to stop your body losing more fat and more protein. High Protein sources are found in meat, chicken, fish, milk, egg, & cheese. High energy sources are found mainly in all kinds of fats, oils, sugars, & pastries.
Eat large amounts of complex and simple carbohydrate such as bread, pasta, cereal, doughnuts, pies, rice, potatoes, honey, dates, & Jam.
Eat large amount of vitamins & minerals which are found mainly in fruits & vegetables. It may be useful to prevent potential deficiencies associated with poor intake, the metabolic disturbances of liver diseases, & drug effects.

If you have poor appetite, low intake, or early satiety, the dietitian will ask you to have small frequent meals & dietary supplement (such as Ensure, Fortisip,.. ect) to meet your body’s increased energy & protein Requirements.



## Cautions ##

1. In patients with severe Hepatic Encephalopathy, or who start to become confused or sleepy should consider the following:

• Limit your dietary protein. In addition, you should cut down either on the meat protein or change to eating vegetables, cereals, grains( beans, hommos, adas), & drinking milk, which contain a protein that can be metabolized much more easily than the meat proteins, which require the liver to break it down & eliminate it. It's important to understand that there's less protein in vegetables and milk than in meat, so an individual would have to eat more of those types of proteins than if they were eating meat protein in order to meet their protein needs in the diet.

• Avoid constipation because constipation aggravates hepatic encephalopathy & make you more confused. So, try to eat foods high in fiber such as fruits, vegetables, bran, brown rice,& drink almost 8 cups of water daily.

2. If you are Diabetic Patient: Restrict simple carbohydrate such as sugars, ice cream, doughnuts, cakes, pies, cookies, jellies, jams, geshta, honey, dates, gelatine,& high sugar Arabic traditional desserts such as kunafah, basbosa, henini, & kleja. Its better to substitute the above simple carbohdrates with complex carbohydrates that is instructed in specific amount by the dietition such as rice, cereal, bread, & macaroni. Fruits can be an alternative to have instead of high sugar desserts.

3. If you have fluid in your abdomen or legs, you should avoid salt & salt containing food in your diet such as canned food, sauces, processed food, & cold meat.

4. If you have Varicies (Abnormal Veins in Esophages, or stomach), you should consider the following guidelines to avoid bleeding of the esophages or stomach:

   • Have small frequent meals ( 3 meals, & 3 snacks).

   • Avoid spices, hot sauces, & seasonings.

   • Remove seeds in food.

   • Soften hard food by adding liquid to diet, or having the food cut into small pieces.

   • Brush your teeth regularly.

What is Your Diet During Your Hospital Stay After Transplantation?
Most patients do not start to eat until the second or third day after the transplant. Your first meal will usually consist of fluids and you will progress rapidly to a full ward diet.
By the end of the first week of eating you will find that the nursing staff, doctors and dieticians are all very concerned about how much food you are eating and you will receive constant inquiries about your food and fluid intake.

• The reason for the concern is that most patients come to transplant in a malnourished state in spite of pushing themselves hard to eat. Many studies have shown that people who are poorly nourished take longer to recover and longer to heal their wounds after an operation and may be more susceptible to infections.

• There are studies to show that liver transplant recipients need a high protein intake as well as a high-energy intake in the period after the operation. Because protein helps your build muscles and tissue, which will help you heal after surgery, eat foods high in protein, such as meat, poultry (i.e. chicken), fish, eggs, cheese, dairy milk products and beans.
  At this stage eating may seem to be one of the hardest things you have ever had to do. You will be asked to supplement your intake with high protein drinks such as Ensure Plus, Resource, and milkshakes. You may also receive large meals with high protein snack sandwiches. Your family is encouraged to bring in some of your favourite home-prepared foods in an effort to increase your intake.

• Occasionally it may be necessary to supplement a patient’s intake with an overnight feeding through a fine tube which passes from the nose down the back of the throat and into the stomach. This happens when the team identifies that the patient is eating poorly and not able to drink enough supplements in the presence of significant weight loss or poor wound healing.

• Any dietary restrictions that were needed before your transplant are no longer necessary. Some patients have high blood sugar levels after their transplant and this may be related to their medication doses. It is not necessary to go onto a special diet to control the blood sugar levels at this stage. Insulin is used to control blood sugar levels as it is much more important to eat enough foods rich in protein and energy or calories. As the medication is reduced the blood sugar levels often normalise.
  If you continue to have problems with fluid retention after the transplant reducing your salt intake may help to make it easier to control the excess fluid.

What Should You Be Concerned About When Going Home After Transplant?
The aim of chronic medical nutrition therapy is prevention. Nutrition therapy can improve the common post transplant problems of obesity, hyperlipidemia, hypertension, diabetes mellitus, and osteoporosis that results from immunosupressent medications in some patients.
During your routine follow up, often Liver transplant doctors will search for any of these side effects & deal with them either by treatment or by changing your immunosuppressive drugs or both.

What are the side effects of the medications that may occur in some patients?
1. Excessive Weight Gain
Excessive weight gain is common after liver transplantation and frequently leads to obesity. Main causes include History of obesity, Hyperphagia) excessive overeating) caused by steroids, Sedentary lifestyle; lack of exercise, & Attitude of "I can eat anything I want"
 

How can you control your weight?

• Try healthier ways of cooking. Instead of frying, try baking, broiling, grilling or steaming foods.

• Pay attention to portion size. Keep in mind that restaurants often serve enormous portions. Don't eat the whole thing. Instead, cut it in half and eat the rest for lunch the next day.

• Read food labels. Watch for the amount of fat and calories.

• If you need to eat between meals, choose high-fibre foods such as crisp crunchy vegetables. Vegetable soups are often satisfying on and are low in fat and calories.

• High fat foods are high in calories. Try to choose the reduced fat alternatives at all times. These include lean meats, lean poultry, fish, reduced-fat spreads and low-fat or reduced-fat dairy products. Try to avoid fried foods and foods laden with oil or cream.

• Drink plenty of water. Choose low calorie drinks such as iced water, tea or coffee without sugar, plain mineral water or soda water, diet soft drinks. This is advisable as long as your doctor says you don't have to control the amount of fluids you drink.

• Choose fresh fruit or fresh fruit combinations to finish off a meal rather than the higher-calorie alternatives such as sweets.

• As you start to feel better, regular exercise will help you regain your strength. Because you may feel tired at first, you should take rest breaks during exercise. Gradually, increase the amount and type of physical activity you enjoy.

2. Hyperlipidemia
Hypercholesterolemia is a risk factor for cardiovascular disease and occurs frequently in post-liver transplant patients. Causes may be related to Weight gain,
Diabetes mellitus,& steroids medications.

How can you deal with hyperlipidemia?

• Choose lower fat food, such as low fat milk, low fat cheese.

• Use low fat alternatives, such as olive oil, corn oil rather than butter & Ghee.

• Limit your intake of sugary foods to an occasional treat - choose diet / low sugar varieties where possible

3. Hypertension

Hypertension usually occurs in post transplant patients as a result of excessive weight gain, High sodium, or medication used.

How can you deal with Hypertension?

• Eat a minimum amount of salt (limit your table salt to ¼ tsp/d)

• Limit your intake of processed foods such as canned food( canned tuna, packaged for microwaving, instant meals for stir-frying), sauces( soya sauce, tomato sauce, hot sauce), mixes(Magie, Indomi, Borritos), pickles, & olives.

• Use lemon, herbs and spices to add flavor, instead of salt.

• Soak any salted food such as olives in the water for ½ hr before eating it.

4. Diabetes Mellitus
Diabetes may be as a result of medication you are taking.

How can you prevent hyperglycemia?

• Eliminate simple sugar such as candies, table sugar, chocolates, honey, jam, gum.

• Measure your blood sugar regulary.

• Eat high fiber foods, such as fruits, vegetables, grains and beans, (but greatly limit fruit juices).

• Use less added fat and salt. Use fat & salt alternatives such as olive oil.corn oil, sunflower oil, lemon, & herbs.

• Eat meals and snacks at regular times every day. Do not skip meals.

• Use sugar alternatives that have little or no calories such as canderal, or corn sugar.

• Increase your physical activity. Exercise helps absorption of excess sugar in blood to the cells.

5. Osteoporosis
Liver disease decreases your ability to absorb vitamin D which plays a part in maintaining the strength of your bones. Research has shown that transplant patients are at higher risk of developing bone fracture as a result of steroids medications, or Decreased estrogen levels in women.

How do you know that you are getting enough calcium and vitamin D in your diet?

• Add calcium to your diet by eating calcium-rich foods, such as low-fat dairy products– including skimmed and low-fat, Cheese, milk, & yoghurt.

• If you are vegetarian , eat large amounts of Green, leafy vegetables, such as broccoli, & spinach, also eat cereals, & grains.

• Choose juices that are supplemented with calcium.

• Other Calcium sources are canned Sardines, salmon, sesame, meso soup & tofo.

• Expose to sun light for half hr daily.

• If you felt that your intake of calcium is still deficit, consult your doctor about calcium supplements.

• Other Nutrition-Related Problems That May Occur as a Result of Immunosuppresent Drugs & Their Nutritional Therapy

Note: Your routine clinic follow-ups, & laboratory tests aims to:
1. Prevent having any problem.
2. Early detect any problem.
3. Treat them if they occur.

What about food poisoning?
As transplanted patients are immunosuppressed it is important to be aware of the possibility of food poisoning. There are two bacteria in particular which may be a serious problem for patients who may be immunosuppressed.
Vibrio vulnificans is a bacterium that may be present in raw shellfish. Although contamination with the bacteria is rare, all transplant patients are advised not to eat any raw shellfish Listeria monocytogenes is a bacterium that is more widespread in our food supply. It also loves to grow in the cold.Foods that may contain listeria include the following: Unpasturised cheese, Foods containing raw eggs eg. mayonnaise

What are the general guidelines that you should consider to prevent food poisoning?

• Defrost frozen food on a plate either in the refrigerator or in a microwave, but not on the counter. Cook food immediately after defrosting.

• Wash utensils, & plates used for preparing raw meat with hot water & soap.

• Wash hands with soap and dry thoroughly, especially after handling raw meat & egg.

• At a party, picnic or family meal, don’t leave food on the table for more than 2 hours. So, put leftovers in the refrigerator or freezer as soon as you finish eating. Put them in shallow dishes so they cool faster. Be sure to eat leftovers in the next few days, before they go bad.

• Cook food properly or use a thermometer when cooking.Cook beef to at least 160°F, poultry to at least 180°F, and fish to at least 140°F.

• DO NOT eat raw animal products such as : unboiled eggs, raw kubbah, salami, soft cheese, cold turkey, martedella, shawerma.

• Seperate raw and ready to eat foods. DO NOT place cooked meat or fish back onto the same plate or container that held the raw meat, unless the container has been thoroughly washed.

• DO NOT use outdated foods, packaged food with a broken seal, or cans that are bulging or have a dent.

• DO NOT use foods that have an unusual odor or a spoiled taste.

• When traveling where contamination is more likely, eat only hot, freshly cooked food. Drink water only if it's been boiled. DO NOT eat raw vegetables or unpeeled fruit.

• When you buy your food buy perishable food such as meat, eggs, and milk last. Shop for groceries when you can take food home right away so that it does not spoil in a hot car.

• Watch Out For Drug Nutrient Interaction!
  Make sure you know if any of your medicines interact with foods. If your taking Cyclosporine you should AVOID Grapefruit. But you can mix the drug with milk or orange juice.

What Should You Consider When Dining Out?

The calorie controlled meal plan can be followed while dining away form home. Especially remember what to eat and how much to eat.

The following guidelines and recommended foods listed below assist the meal planner with choosing low calorie, low fat, low sugar foods:

• Appetizers:
  Recommended foods include raw vegetables, all kind of salads without dressing added (add unlimited amount of lemon & vinegar, but 1 tsp of olive oil), Soup (clear broth not cream based soup), 2 pieces of dates, & brown bread (without butter added). Avoid chips, crackers or nuts.

• Beverages:
  Recommended foods include iced tea, diet soft drinks, plain coffee, tea (use sugar alternative such as canderal rather than sugar), mineral water, & fresh unsweetened fruit juices (1/2 cup). Foods not recommended are alcoholic beverages, sweetened juices and regular soft drinks.

• Main course:
  Recommended foods include roasted, baked, broiled or grilled meats, fish or poultry. Trim extra fat, remove skin from poultry; order without gravy. You can have your meal with boiled rice, boiled potato (rather than fried fries), or macaroni. Ask the waiter to prepare your food with a little or no salt added.
  Foods not recommended include any meats that are fried, breaded, sautéed, creamed or have added sauces or gravies. Hard cooked or scrambled eggs are recommended rather than fried eggs or omelets.

• Desserts:
  Choose fruits or fresh fruit salads with unsweetened fruit juice on the side rather than high calorie sweets.
  
  Finally, you always have access to the liver transplant dietitian. If you have any inquiries about your nutrition at any stage, you should not hesitate to contact the dietitian. Similarly if you are having difficulty controlling your weight at home after your transplant you should contact the dietitian earlier rather than later.
  
  ِArabic References:
  1. مراد,كارلا, 2004. أسرار التغذية مع كارل
  English References
  1. Eleanor NW, Corinne BC, Sharon RR, Understanding Normal & clinical Nutrition.2002.6th edition.
  2. Hasse JM, Blue LS, Crippin JS, Goldstein RM, Jennings LW, Gonwa TA, et al. The effect of nutritional status on length of stay and clinical outcomes following liver transplantation. J Am Diet Assoc 1994;94 (suppl):A-38.
  3. James Richards, Bridget Gunson, Jill Johnson and James Neuberger. Weight gain & obesity after liver transplantation. Transplant International 2005;18:461-469
  4. L.Kathleen Mahan, Sylvia Escott-Stump, Krause’s Food, Nutrition, & Diet therapy, 2000, 10th edition
  5. Manual of clinical Nutrion,2000,6th edition.
  6. Palmer M, Schaffner F, Thung SN. Excessive weight gain after liver transplantation. Transplant 1991;51:797-800.
  7. Perez R. Managing nutrition problems in transplant patients. Nutrition Clinical Practice 1993; 8:28-32.
  8. Pikul J, Sharpe MD, Lowndes R, Chent CN. Degree of preoperative malnutrition is predictive of postoperative morbidity and mortality in liver transplant recipients. Transplantation 1994;57:469-472.