Clinical Dietitian Magee Rehabilitation Hospital Philadelphia, Pennsylvania, United States
Disclosure(s):
Sumer Alani, MS, RD, LDN: No relevant financial relationship(s) with ineligible companies to disclose.
Objectives: Liver cirrhosis is often accompanied with acute kidney injury (AKI). Hepatorenal syndrome type AKI (HRS-AKI) is a common form that presents and is characterized by diminished renal function with no intrinsic kidney abnormality or disease. Orthotopic liver transplantation (OLT) is often a last resort for both cirrhosis and HRS-AKI, however success rates vary in reversing AKI with OLT.
Methods: A 51-year-old Caucasian male presented to Magee Rehabilitation Hospital post-OLT. The patient had a history of an AKI leading up to his OLT that was not associated with any intrinsic renal abnormality or disease. The patient was admitted 2 months after surgery with altered hepatic and renal function and large volume ascites. Renal diet and oral nutrition supplements were prescribed along with supplements to improve recovery: magnesium, pyridoxine, thiamine, and folate. Medical nutrition therapy (MNT) was applied alongside medical interventions to target both hepatic and renal health. The patient’s diet and supplements met transplant needs while monitoring and adjusting for electrolyte and fluid disturbances to resolve AKI symptoms.
Results: The patient maintained a high calorie (30-35 kcal/kg), moderate protein (0.8-1.1 g/kg). Appetite and oral intake were well managed with MNT. Liver function tests showed slow but consistent improvements. However, HRS-AKI symptoms did not resolve proportionally with hepatic function. In fact, renal function decreased rapidly by day 8 and eGFR dropped to 34 mL/minute. Creatinine and urea nitrogen reached a peak of 2.29 and 94 mg/dL. The diet was further restricted by limiting fluids and potassium to 1.2 L and 2 g respectively. Oral nutrition supplements were switched to a renal formula with optimized electrolyte balance. The patient’s eGFR and creatinine reached normal values of 70 mL/minute and 1.24 mg/dL by discharge, day 23. Although urea nitrogen did not reach normal levels, values reduced from critically high concentrations of 94 to 50 mg/dL. Upon discharge, the HRS-AKI symptoms and ascites resolved, and the patient went home on a liberalized renal diet.
Conclusions: This case report demonstrates how MNT can be a powerful tool for the improvement of HRS-AKI symptoms associated with OLT. Further studies should investigate if standardized MNT practices can be established to improve OLT prognosis.
