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
Liver
Portal
vein
Coronary
vein
Splenic
vein
Dallas, TX • November 2–4, 2012
Functions of the Liver
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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
• 7th 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
Portal
systemic
collaterals
Distorted
sinusoidal
architecture
leads to
increased
resistance
Portal
vein
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)
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Portal Hypertension
GI Bleed / Varices
Ascites
Systemic Bacterial Peritonitis (SBP)
Hepatorenal Syndrome
Hyponatremia
Encephalopathy
Dallas, TX • November 2–4, 2012
Cirrhotic Liver
Portal
systemic
collaterals
Distorted
sinusoidal
architecture
leads to
increased
resistance
Portal
vein
Splenomegaly
Dallas, TX • November 2–4, 2012
ESLD Catch 22
Portal HTN
Portal Pressure
Vasodilation of
Splenic Vessels
Systemic BP
Systemic
Vasodilation
SVR
Varices
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)
N Engl J Med 1988; 319:983
Dallas, TX • November 2–4, 2012
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
Na+/H2O
Ascites
• 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
Elsevier (2010)
Grade I
Mild
No Treatment
Grade 2
Moderate
Na+
Restriction
Diuretics
Grade 3
Large
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:
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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
Toxins
NH3
Shunting
Failure to
metabolize
NH3
GABA-BD
receptors
Bacterial action
Protein load
Dallas, TX • November 2–4, 2012
Encephalopathy
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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
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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:
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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?
• Model for End Stage Liver Disease (MELD)
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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
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Na+
K+
Mg+
Phos+
• Other labs:
– WBC – infection
– H&Hbleeding/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
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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
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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,
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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
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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, 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,
25(4): 638-45.
Runyon, B. (2009). Management of adult patients with ascites due to
cirrhosis: An update. Hepatology, 49(6), 2087-2107.
Singhal S, Baikati KK, Jabbour II, Anand S. (2012). Management of
refractory ascites. American Journal of Therapeutics, Mar; 19(2): 12132.
Tsiaousi, E., Hatzitolios, A, Trygonis, S., Savopoulos, C. (2008).
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527-533.
Zhao, V., & Ziegler, T. (2010). Nutrition support in end stageliver
disease. Critical Care Nursing Clinics of North America,
22(3),
1-12.
Dallas, TX
• November
2–4, 2012