Nutrition Care for Diabetes after Liver Transplant

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Nutrition Care for Diabetes after Liver Transplant

• Angela Matthewson, RD LD CNSD
• Instructor in Nutrition, Mayo Clinic
• Jacksonville Dietetics Association
• September 18, 2009

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Objectives

• Recognize incidence, risk factors, and
  consequences of post-transplant diabetes mellitus
  (PTDM) among liver recipients
• Identify short-term and long-term complications
  related to PTDM
• Understand role of registered dietitian (RD) in
  management of PTDM
• Describe use of Stages of Change in the
  management of PTDM

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Liver Transplant

• 5 year survival after Orthotopic Liver Transplant
  (OLT)
• 70-80
• Good Quality of Life
• New Challenge long-term management
• Cardiovascular disease among most serious
  conditions to develop after transplant
• Diabetes leading risk factor for CVD

Benten 2009
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Immunosuppressant Side Effects

• Major cause long-term mortality morbidity after
  OLT
• gt1/2 deaths after 3 year survival
• Atherosclerotic cardiovascular disease (ASCVD)
• Correct or control potentially reversible CV risk
  factors (i.e. DM, dyslipidemia, obesity,
  hypertension)
• De novo malignancies
• Regular surveillance

Benten 2009, Reuben 2001
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Drug Effects
Adverse effect Ciclo-sporin Tacro-limus Gluco-corticoids Azathioprine Myco-phenolate mofetil mTOR inhibitors
Arterial HTN - -
Hyperglycemia, DM - (?) - - -
Hyperlipidemia - -
Nephrotoxicity (K, Mg2) (K, Mg2) - - - (proteinuria)
Benten
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DM Etiology

• Tissue resistance to insulin-mediated glucose
  uptake
• ß-cell failure, inability to compensate for
  insulin resistance

Rizvi
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Immunosuppressants DM Etiology

• Corticosteroids
• Increase insulin resistance
• Increase hepatic gluconeogenesis
• Decrease glucose use in muscle and adipose tissue
• Calcineurin Inhibitors (CNIs)
• Increase insulin resistance
• Pancreatic beta-cell toxicity

Rizvi 2004, Marchetti 2005
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Hyperglycemia Outcomes

• Short-term consequences
• Infections
• Graft rejection
• Long-term consequences
• Microvascular complications
• Progressive HCV disease
• Increased risk ASCVD

Rizvi 2004, Swift 2006
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DM Other Side Effects

• DM risk increases with obesity sedentary
  lifestyle
• Microvascular complications responsible for most
  adverse outcomes
• Link between DM2 CVD major determinant early
  mortality
• Risk for future CV event Presence of DM2
  Established CVD
• DM v. no DM 2 to 4 fold increased risk for MI

Rizvi, Horan
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DM Other Side Effects

• Expanding perception of DM
• Cluster of risks
• Each impacts at least one other
• Each contributes to overall risk ASCVD
• Immunosuppressants increase risk of each

Rizvi 2004, Horan 2006, Beckman
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Immunosuppressant Side Effects
Risk ASCVD
Obesity/Overweight
Dyslipidemia
Diet
Hyperglycemia / DM
Arterial HTN
Nephrotoxicity
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PTDM Diagnosis Incidence

• American Diabetes Association World Health
  Organization diagnostic criteria
• Fasting plasma glucose 126 mg/dL (7 mM)
• OLT recipients pre-transplant
• 10-30
• New-onset diabetes mellitus (NODM) in OLT
  recipients
• 20-40
• Incidence is cumulative over time

Marchetti 2005, Benten 2009, Ma 2005, Oufroukhi
2008, Steinmüller 2000, Reuben 2001
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PTDM Risk Factors

• Family history
• African-American or Hispanic ethnicity
• Male gender
• Age gt40 years
• Increased weight
• Metabolic syndrome

• HCV
• Immunosuppressant type/dose CNI, Steroids
• Pre-transplant glycemia
• Alcohol
• Recurrent viral disease

Marchetti 2005, Benten 2009, Ma 2005, Oufroukhi
2008, Steinmüller 2000, Reuben 2001
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Diabetes Impact

• What can we do?

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DM Change Outcomes

• Improved Glycemic control ? decreased
  microvascular risk, DM dyslipidemia
• Hemoglobin A1c
• DCCT 1 decrease ? 60 decrease microvascular
  complication
• UKPDS (over 10 year follow-up) every 1
  decreases ? 37 decrease microvascular
  complications
• 5 weight loss ?
• Increased insulin sensitivity
• Decreased fasting blood glucose
• Decreased medication needs

Horan 2006, Beckman
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DM Interventions

• Lifestyle modification
• Diabetes Self-management Education (DSME)
• General guidelines
• More Intensive
• Clear guiding theory
• Face-to-face delivery
• Inclusion physical activity
• Include cognitive restructuring and
  patient/educator interaction
• Team management

Rizvi 2004, Skinner 2008
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DM Interventions

• Individual counseling with RD
• 1.9 reduction in HbA1c with intensive RD
  intervention
• Better outcomes than with medication alone
• Patient-tailored
• Simplified educations among lower literacy
  patients ? Improved comprehension and compliance

Rizvi 2004, Swift 2006, Bantle 2008 2004, Horan
2006, Wilson
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DM Interventions

• Structured group education
• Greater weight loss
• Less likely to smoke
• Greater changes in illness beliefs
• Lower depression
• More facilitative, less didactic education
• Greater change in illness beliefs
• Patient empowerment patients involved in
  setting realistic goals according to their
  lifestyles

Davies 2008, Skinner 2008, Horan 2006
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DM Nutrition Care

• No more taboo foods
• Research refutes a specific diabetic diet
• Meal planning based on individual preferences ?
  better compliance and achievement metabolic goals

Rizvi 2004, Swift 2006, Bantle 2008, Horan 2006
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DM Nutrition Care

• Carbohydrate consistency
• 45-65 total calories
• Provide energy, fiber, vitamins, minerals
• Meals may vary from each other, but daily amounts
  at each should be constant
• Snacks not required
• Unnecessary to eliminate sucrose
• No research to support one method versus another
  for carbohydrate content estimation

Bantle 2008, Swift 2006
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DM Transtheoretical Model / Stages of Change

• Precontemplation No intent to change behavior
  within next 6 months
• Contemplation Stated intent to change behavior
  within next 6 months
• Preparation Intention to take specific steps
  toward behavior change within the next month
• Action Overt behavior changes within the past 6
  months - not yet well-established
• Maintenance Behavior changes have lasted greater
  than 6 months

Vallis 2004
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Traditional interventions are action-oriented

• Those in pre-action stages do not benefit

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DM Transtheoretical Model / Stages of Change

• Individuals with DM in action phases compared to
  pre-action stages
• Fewer calories from fat
• Lower BMI
• More likely DSME in past year
• More frequent MD appointments
• Less likely to smoke
• Fewer psychosocial problems
• Older, more females, more insulin users

Vallis 2004
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DM Transtheoretical Model / Stages of Change

• Chicken or egg?
• Controllable
• DSME medical follow-up frequency
• Social interventions to improve QoL support
• Non-controllable
• Take factors into account when intervening

Vallis 2004
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PTDM Management

• Immediate post-transplant
• In-patient education
• Motivate to participate in glycemic control
• Rationale to limit carbohydrate foods to 3 meals
• Carbohydrate foods
• Non-carbohydrate snack examples
• Refer as needed for outpatient follow-up after
  discharge

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PTDM Management

• Commonly Used Insulin Preparations post-OLT

Preparation Action Onset (h) Peak Action (h) Effective Action duration (h) Maximum duration (h)
Insulin aspart (NovoLog) ¼ - ½ ½ - 1 ¼ 3-4 4-6
Basal Insulin 3-4 8-16 18-20 20-24
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PTDM Management

• Chronic post-transplant
• All patients attend 4 month follow-up
• RD education
• Screen for additional education needs

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Chronic Post-transplant

• Content Mediterranean diet/lifestyle
• Goal
• Reduce risk factors for ASCVD
• Manage long-term immunosuppressant side effects
• Format interactive
• Stages of change
• Provide motivation for behavior change
• Encourage incremental steps
• Patient-centered
• Provide patients with lipid profiles
• Instruct to set personal goals

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Chronic Post-transplant

• Diabetes Assessment Risk Tool
• Diagnosis status, BMI, dyslipidemia,
  hypertension, medication/insulin
• Referral as needed to Diabetes Education Program

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Case Study 1 - AB

• 61 y.o. female
• OLT 8/3/09 for EtOH
• No DM pre-OLT required insulin gtt in SICU
  transitioned to Novolog sliding scale once
  transferred to transplant ward

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Case Study 1 - AB

• Nutrition Assessment 8/3/09
• Intubated and sedated no family present.
  Therefore, no diet/weight hx obtained.
• Nutrition Follow-up 8/7/09
• Height 158 cm, 52.2 kg, 20.9 BMI
• Weight hx dry weight stable PTA, 12 weight loss
  in 2 weeks represents severe fluid fluctuation
• Diet hx Pt eating 3 meals per day, gt75 each
• Labs WBG 112-144 past 24 hrs
• Estimated nutrition needs 1500 kcal (29
  kcal/kg), 73 g protein (1.4 g/kg)

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Case Study 1 - AB

• Education
• Rationale to restrict carbohydrates to meals only
• Sliding scale insulin given at meals and not
  effective between
• Relationship between glycemic control and wound
  healing / infection risk / rejection risk
• Food safety principles also reviewed
• Outcome
• Verbalized and demonstrated understanding
• Goals
• Able to state relationship between diet and lab
  values
• Identify ways to modify current intake
• Identify food selection principles

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Case Study 1 - AB

• Nutrition Diagnosis Knowledge deficit related to
  dietary guidelines for steroid induced diabetes
  as evidenced by patient reported lack of previous
  exposure.

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Case Study 2 - GD

• 69 y.o. female
• OLT 7/8/09 for cryptogenic cirrhosis
• DM pre-transplant insulin drip initially
  post-transplant, transitioned to Novolog sliding
  scale

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Case Study 2 - GD

• Nutrition assessment 7/10/09
• Height 164 cm, Admit weight 82 kg, estimated
  dry weight 72.5 kg, BMI 27 (WNL)
• Weight history Fluctuated with fluid, unable to
  determine underlying dry weight changes
• Diet history Ate 3 meals, plus 2 snacks and
  Ensures at home. Current appetite decreased, but
  forcing self to eat 3 meals
• Estimated nutrition needs 1725 kcal (BEE x 1.3),
  94 g protein (1.3 g/kg)

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Case Study 2 - GD

• Assessment, continued
• Education food safety information reviewed
• Intervention Glucerna with breakfast and dinner
• Nutrition follow-up 7/13/09
• Current intake 3 meals but very small amounts,
  drinking supplements between
• Labs WBG 152-222

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Case Study 2 - GD

• Education
• Rationale to restrict carbohydrates to meals only
• Sliding scale insulin given at meals and not
  effective between
• Relationship between glycemic control and wound
  healing / infection risk / rejection risk
• Food safety principles also reviewed
• Outcome
• Verbalized and demonstrated understanding
• Goals
• Able to state relationship between diet and lab
  values
• Identify ways to modify current intake
• Identify food selection principles

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Case Study 2 - GD

• Nutrition follow-up 7/16/09
• PO somewhat improved. 3 small meals supplement
  with each
• Education
• Reviewed prior topics
• Patient and spouse without questions
• Outcome
• Verbalization of understanding
• State who to call if questions

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Case Study 2 - GD

• Nutrition Diagnosis Knowledge deficit related to
  dietary guidelines for steroid exacerbated
  diabetes as evidenced by consumption of
  carbohydrates between meals.

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Conclusions

• PTDM is common and serious complication post-OLT
• Proper management abates negative sequelae
• Interventions should include multidisciplinary
  team with consistent message
• RD provides nutrition component
• Goals, format tailored to patient

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References

• Bantle JP, et al. Nutrition recommendations and
  interventions for diabetes a position statement
  of the American Diabetes Association. Diabetes
  Care 2008 31(S1) S61-S78.
• Benten D, et al. Orthotopic liver transplantation
  and what to do during follow-up recommendations
  for the practitioner. Nature Clinical Practice
  Gastroenterology and Hepatology 2009 6(1)
  23-36.
• Davies MJ, et al. Effectiveness of Diabetes
  Education and Self Management for Ongoing and
  Newly Diagnosed (DESMOND) programme for people
  with newly diagnosed type 2 diabetes cluster
  randomised controlled trial. British Medical
  Journal 2008 336 491-495.
• Endotext. http//www.endotext.org/diabetes/diabete
  s20/ch01s06.html. Accessed September 6, 2009.
• Horan KL, et al. An overview of nutrition and
  diabetes management. Topics in Clinical Nutrition
  2006 21(4)328-340.
• Ma Y, Yan W. Chronic hepatitis C virus infection
  and post-liver transplantation diabetes mellitus.
  World Journal of Gastroenterology 2005 11(39)
  6085-6089.
• Marchetti P. New-onset diabetes after liver
  transplantation from pathogenesis to management.
  Liver Transplantation 200511(6) 612-620.

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References

• Oufrouki L, et al. Predictive factors for
  posttransplant diabetes mellitus within one-year
  of liver transplantation. Transplantaion 200885
  1436-1442.
• Reuben A. Long-term management of the liver
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  obesity. Liver Transplantation 2001 7(11)
  S13-S21.
• Rizvi AA. Type 2 diabetes epidemiologic trends,
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  in therapeutic approach. Southern Medical Journal
  2004 97(11) 1079-1087.
• Skinner TC, et al. Educator talk and patient
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• Steinmüller TH. Liver transplantation and
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• Swift CS, Boucher JL. Nutrition therapy for the
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• Vallis 2004 M, et al. Stages of change for
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• Wilson C, et al. Effects of clinical nutrition
  education and educator discipline on glycemic
  control outcomes in the Indian Health Service.
  Diabetes Care 2003 29(9) 2500-2504