Pre‐operative nutritional support in children with end‐stage liver disease accepted for liver transplantation: An approach to management

Abstract

Pre-operative nutritional support was studied in 28 children with end-stage liver disease awaiting orthotopic liver transplantation. Nasogastric supplemental administration of a standard semi-elemental enteral nutritional formula was compared with a similar formula enriched with branched chain amino acids, and with a group receiving oral nutrition only. The duration of treatment in all groups was similar (mean 90 days). Energy intakes in the supplemented groups were 120-150% of recommended daily intakes (RDI), whereas ad libitum intakes in the oral group ranged 58-100% RDI. A significant improvement in mean Z-score for body weight (denoting catch-up) was noted only in those children who received nasogastric supplements enriched with branched-chain amino acids. The standard enterally-fed group maintained their body weight and Z-scores did not change significantly. In contrast, body weight Z-scores in those fed orally declined significantly. Nutritional supportive therapy of malnourished children with end-stage liver disease can minimize or improve nutritional status in children awaiting liver transplantation. The use of nutritional formulae rich in branched-chain amino acids may have nutritional advantages in children with chronic liver disease which require further study and evaluation.

Biliary Atresia: Clinical Profiles, Risk Factors, and Outcomes of 755 Patients Listed for Liver Transplantation

“…Infants are particularly suited to consideration for a scheduled living donor LT or a left-lateral (split) segment of an adult cadaver donor because of their greater risk of dying while waiting for LT, particularly infants with blood type B. Cadaveric technical variant donors do carry an increased risk of graft problems, but this may be outweighed by the benefits of receiving a timely LT. These data also reemphasize the significance of nutritional deficit as an important risk factor for poor outcome, [17][18][19][20][21] pointing to another area of management in which improvement may be possible. 18,20 After LT, infants remain at greater risk, with nonsurgical factors, such as nutritional status, choice of primary immunosuppression, and infection, the major contributors to mortality All factors listed had P < .05.…”

“…These data also reemphasize the significance of nutritional deficit as an important risk factor for poor outcome, [17][18][19][20][21] pointing to another area of management in which improvement may be possible. 18,20 After LT, infants remain at greater risk, with nonsurgical factors, such as nutritional status, choice of primary immunosuppression, and infection, the major contributors to mortality All factors listed had P < .05. Univariate factors with P # .15 were included in the multivariate analyses.…”

“…Specifically, aggressive nutritional support with correction of nutritional deficits while awaiting LT is likely to improve outcome. [17][18][19][20][21][22][23] Infants with BA awaiting LT are hypermetabolic in general and catabolic during fasting, 27 and trials of nocturnal enteral nutrition, specifically with branched-chain amino acidsupplemented formula, have demonstrated significant nutritional benefits. 17,18 Attention to post-LT nutritional support, particularly in patients who are already undernourished, would also seem advisable.…”

Risk Factors for Rejection and Infection in Pediatric Liver Transplantation

“…An individualized approach to the prevention of EBV disease and PTLD (28), would be particularly relevant to infants, given the high risk of these problems in CMV-or EBV-naive patients. Undernutrition is a well-documented risk factor, particularly in biliary atresia (3), modifiable by aggressive nutritional support (29,30). For reasons that are not immediately obvious, the type of donor organ (split, deceased donor cut-down and living donor organ vs. whole) appears to be a factor in both bacterial and viral infections, but not rejection.…”

A prospective study on the effect of recipient nutritional status on outcome in liver transplantation

“…The use of branched chain amino acid (BCAA) feeds is contentious. Some evidence suggests that BCAA-enriched feeds may be beneficial [9], but this is clearly an area that requires further evaluation. It has also been suggested that total parenteral nutrition may be of benefit in improving nitrogen balance and reducing time spent on ITU after OLT [27].…”