terapi nutrisi pada hepar kronis (1)
TRANSCRIPT
Terapi NutrisiTerapi Nutrisipadapada
Penyakit Hati KronikPenyakit Hati Kronik
Dani RosdianaDani RosdianaBagian Penyakit DalamBagian Penyakit Dalam
FK UNRI Pekanbaru/ RS Arifin AhmadFK UNRI Pekanbaru/ RS Arifin Ahmad
Hati memegang peran sentralHati memegang peran sentral
Metabolisme tubuhGangguan faal hati berat, misal Sirosis hati sudah disertai kapilarisasi sinusoid
Metabolisme pasti terganggu
* CLD / Liver Cirrhosis: chronic inflammation, esp. in advanced stage liver cells injury functi- onal failure nutrient metabolism disturbances malnutrition morbidity and mortality
* The liver: plays a central and fundamental role of nutrition and body nutrient metabolism
Faktor penyebab malnutrisi pada penyakit hati kronik
• Asupan kurang• Gangguan metabolisme dan penyimpanan• Gangguan sintesis• Malabsorpsi dan maldigesti• Pengaruh terapi : Neomisin Laktulosa Diuretika Kolistiramin
ChronicLiver
DiseasesReduced Net
Nutrient Intake
Metabolicdisturbances Malnutrition
(P.E.M)
MorbidityMortality
The interplay of the factors influencing the progression or regression of Chronic Liver Diseases and Malnutrition
Malnutrition (PEM) in Chronic Liver Diseases
* PEM is common in CLD and positively correlated with functional severity of liver injury. * Prevalences of PEM were similar in alcoholic and non-alcoholic LC
* PEM present in 20% of well-compensated LC pts. and more than 60% severe LC pts. (Italian Multicentre Cooperative Project on Nutrition in LC. 1994)
(ESPEN consensus, 1997)
Malnutrition (PEM) in Chronic Liver Diseases
0
10
20
30
40
Child-Pugh AChild-Pugh BChild-Pugh C
TSF < 5th %(triceps skinfold)
MAMC < 5th % (midarm muscle circumference)
The proportion of severe malnutrition of Liver Cirrhotic patients in the three Child-Pugh classes. (n= 120)
(Caregaro et al, 1996)
a. GI disturbances: - low intake, anorexia, nausea, vomit, dyspepsia - malabsorbsion, steatorrhea, diarrhea b. Metabolic changes: - liver failure, hormonal changes, hypermetabolic, - nutrient deficiencies (low intake & storage), etc c. Complications of LC: - infections, GI bleeding, encephalopathy, etc d. Management of LC: - fasting (surgery), false diet, antibiotics, etc.
Malnutrition (PEM) in Chronic Liver Diseases
The etiology of PEM is multifactorial:
Asesmen klinik, malnutrisi pd Penyakit hati kronik
Didasarkan pada : Riwayat penyakit Riwayat gizi Pemeriksaan fisik Laboratorium
Pemeriksaan penunjang
BMI : sulit diinterpretasi Asites Edema
Skin-fold thicknessArm muscle circumference
Pemeriksaan laboratorium :
RutinHepatic secretory protein Albumin Transferin
Subjective global assesment
Riwayat penyakit
• Perubahan berat badan• Perubahan asupan makanan• Keluhan gastrointestinal• Kapasitas fungsional• Penyakit / keadaan yang dapat dicurigai sebagai penyebab
Subjective global assessment
Pemeriksaan fisik
• Lemak subkutan• Muscle wasting• Edema pretibia / anasarca• Asites
* Nutritional support may improve - nutritional status, - liver functions & regeneration, - body regeneration, - short-term and long-term prognosis. * Nutritional therapy should be included in the management of LC pts., consist of - oral dietetics, - enteral nutrition, - parenteral nutrition.Dr. F. Soemanto PM., 2001
Kebutuhan nutrisi pasien penyakit hati kronik berat
Malnutrisikalori-proteinHiperkatabolik
• Tinggi kalori dan tinggi protein• Kalori basal dan tinggi protein• Tinggi kalori dan protein standar
A. Kebutuhan Kalori* Stable LC: 35 - 40 kcal/kgBW/day Unstable LC, w/ complication: 40 - 45 kcal
* Carbohydrate and Lipid (30-35% total calorie)
Pertimbangan
• Sering dengan P-S shunting• Tinggi protein memacu ensefalopati • Sering intoleransi
Tinggi kalori danprotein standar
Tinggi kalori = 1,5 kali basal
B. Protein
Malnutrisi protein-kaloriBelum pernah ensefalopati 1,5 gram/Kg BB
Ensefalopati kronikMalnutrisi protein-kalori BCAA
* Stable LC: 1.0 - 1.2 g/kgBW/day (60-80 g/day) * LC w/ hypoalbumin/edema/ascites: 1.5 g/kgBW/day
* LC w/ encephalopathy: 0.6 g/kgBW/day plus BCAA step by step increasing to normal intake
C. LemakKeuntungan
Kalori tinggi dalam vol sama Tidak memacu insulin/metabolic rate Mengatasi defisiensi asam lemak esensial Rasanya enak
Kerugiannya :
steatorrhe, steatosis / over feeding
Dapat sampai 45%
D. Mineral dan trace elementD. Mineral dan trace element
Diit rendah garam Hiponatremia ringan bukan CI diit rendah garam
Asites dan edema akibatreabsorpsi air dan garam
Kadar Na absolut tinggi
* LC w/ edema, ascites: fluid & Na+ restriction Fluid: 0.5 - 1.5 L/day, Na+: 500 - 2000 mg/day
Nutrisi parenteral
Tujuan : nutrisi tambahan bukan nutrisi parenteral total (TPN)
Indikasi TPN : - Iskhemia usus - IBD berat - Fistula enterokutan - Divertikulitis berat - Mukositis berat - Pasca reseksi usus - Obstruksi SC
Prinsip nutrisi parenteral
• Dapat mencegah hiperkatabolik• Glukosa tunggal bukan pilihan tepat• BCAA ? Biasanya kadarnya menurun• perhatikan volue karena asites dan edema
Lemak dapat digunakan hanya harus hati-hatiBerbasis asam amino