Chapter 13: Nutrition Management of Pediatric Patients Undergoing Liver Transplantation or Intestinal Transplantation

NUTRITION AFTER LIVER TRANSPLANTATION

The rates of morbidity and mortality following liver transplantation are directly related to the degree of malnutrition at the time of transplantation. Pediatric patients, like adults, are predisposed to all of the consequences of end-stage liver disease, such as ascites, pruritus, encephalopathy, and portal hypertension, but the impact on growth and development is unique to the pediatric population.¹ Protein-energy malnutrition and growth failure are an inevitable consequence observed in 60% of infants and children with chronic liver disease.²

Although the exact pathophysiology of this process is not fully understood, many different mechanisms within the disease process can contribute to the early onset of malnutrition. The nutritional care of infants and children with end-stage liver disease requires diligent monitoring and aggressive support by the entire health care team to ensure optimal transplant outcomes.

The rapid deterioration of nutritional status and the profound complications of end-stage liver disease have made early liver transplant evaluation imperative. Malnutrition is one of the major factors adversely affecting the survival of infants and children on transplant waiting lists, and the one in which we can have the greatest impact on outcome.³ Therefore, the goals of nutritional support prior to transplant should be focused on the prevention of any further liver injury, the minimization of nutritional depletion, conservation of growth, maintenance of lean body mass (LBM), and control of disease-related complications. One valuable recommendation is that children with mid-upper arm muscle circumference (MUAC) falling below the fifth percentile be initiated on aggressive nutrition support regimens prior to transplantation.⁴

Liver transplantation has become a standard and effective life-saving intervention for infants and children with acute and chronic liver failure. With significant advances in surgical techniques, the development of variant technical procedures involving allograft reduction, and the improvement of long-term immunosuppressant medications, liver transplantation has now become a valid therapy for pediatric patients.⁵ In the past, the need to size-match cadaveric livers had severely restricted pediatric transplantation and led to inflated rates of death among patients on transplant waiting lists. With the ability to use reduced-sized cadaveric grafts or living-related donation, more donor organs are now available. Survival rates in most experienced pediatric liver transplant centers approach 90% at 1 year, and the quality of life for most patients after transplant has significantly improved.⁶ These advances have now shifted our principal focus from purely supportive disease management to treatment measures for improving the patient's clinical status before transplantation. The one metric that can make the most impact upon outcome is nutritional status. A child who is experiencing growth failure due to progressive liver disease is more likely to succumb prior to transplantation.⁷

Patients who have advanced liver disease are unable to maintain nutritional status, even with intakes above normal, because of increased energy requirements, the interference of the metabolism of nutrients, and vitamin/mineral deficiencies.⁸ Infant formulas containing ...