Your diet during your hospital stay after transplantation
Most patients do not start to eat until the second or third day after the transplant. Your first meal will usually consist of fluids and you will progress rapidly to a full ward diet.
By the end of the first week of eating you will find that the nursing staff, the doctors and the dietitian are all very concerned about how much food you are eating and you will receive constant inquiries about your food and fluid intake.
The reason for the concern is that most patients come to transplant in a malnourished state in spite of pushing themselves hard to eat. Many studies have shown that people who are poorly nourished take longer to recover and longer to heal their wounds after an operation and may be more susceptible to infections.
There are studies to show that liver transplant recipients need a high protein intake as well as a high-energy intake in the period after the operation. It also seems that liver transplant patients go through a period where they need lots of calories just to maintain their weight and in fact may lose weight rapidly even on a very high energy intake.
At this stage eating may seem to be one of the hardest things you have ever had to do. You will receive constant reminders from all the Transplant Team about eating enough food to help your wound to heal and to prevent further weight loss.
You will be asked to supplement your intake with high protein drinks such as Ensure Plus, Resource, Sustagen and milkshakes. You may find your drinks and canned fruit “spiked” with Polyjoule. Polyjoule is a form of glucose that does not have the sweetness of sugar or glucose.
You may receive large meals. You are not expected to eat all the food at one meal but rather to spread it out over the day, so that you spend your day grazing. Your family is encouraged to bring in some of your favourite home-prepared foods in an effort to increase your intake.
Occasionally it may be necessary to supplement a patient’s intake with an overnight feeding through a fine tube which passes from the nose down the back of the throat and into the stomach. This happens when the team identifies that the patient is eating poorly, and not able to drink enough supplements in the presence of significant weight loss or poor wound healing.
The dietitian will monitor your weight and nutritional progress closely and you will constantly be pushed to increase your protein and energy intake. It will be reassuring for you to remember that these increased requirements do not last forever.
The dietitian will discuss your ideal or preferred weight with you. When you are nearing this goal you will need to reduce your food intake dramatically, as there is a great tendency to gain weight rapidly several months after transplant. Long-term weight control may be a serious problem in the future if you do not reduce your intake when advised to do so.
Any dietary restrictions that were needed before your transplant are no longer necessary. Some patients have high blood sugar levels after their transplant and this may be related to their medication doses. It is not necessary to go onto a special diet to control the blood sugar levels at this stage. Insulin is used to control blood sugar levels as it is much more important to eat enough foods rich in protein and energy or calories. As the medication is reduced the blood sugar levels often normalise.
If you continue to have problems with fluid retention after the transplant reducing your salt intake may help to make it easier to control the excess fluid.
Your diet when you go home after transplant
By the time most people leave hospital the emphasis on eating has changed. Some may have started to gain weight prior to leaving hospital. This weight gain will continue out of hospital with very little effort. At this time your taste buds may be returning to normal. Food is starting to taste as it should and you are able to enjoy your food with a renewed interest. Unfortunately this combined with the fact that you now have a liver that works and the high prednisone doses means that it is now all too easy to gain weight.
Prednisone has the effect of stimulating your appetite at the doses you are taking when you go home. Patients frequently say that they no longer know when they have eaten enough and that they are always hungry in the early days after discharge from hospital. They also say that this effect may last for years.
It is very important to reduce your food intake when you are within four to five kilograms of your goal or desired weight. You will gain the remaining weight without really trying.
Weight control is the most important nutritional issue when you are discharged after transplantation. Rapid excessive weight gain may affect your liver function tests. Regular exercise and a sensible eating plan will help to control your weight.
Your exercise program should start from the time you leave hospital even if you are still significantly underweight at this stage. Gentle regular exercise will not harm your new liver nor will it open up the scars.
The following guidelines will help you in the struggle to control your weight:
Try to eat regular meals
Frequent snacking between meals will make it difficult for you to control your weight. If you need to eat between meals, choose high-fibre foods such as crisp crunchy vegetables. Vegetable soups are often satisfying on a cold winter’s day and are low in fat and calories.
High fat foods are high in calories or kilojoules. Try to choose the reduced fat alternatives at all times. These include lean meats, lean poultry, fish, reduced-fat spreads and low-fat or reduced-fat dairy products. Try to avoid fried foods and foods laden with oil or cream.
Fluids are important. Choose low calorie drinks such as iced water, tea or coffee without sugar, plain mineral water or soda water, diet soft drinks and diet cordial.
Vegetables, including potatoes and cereals such as bread, rice and pasta should provide the basis of your meals with smaller serves of lean meats, lean poultry, fish etc rather than the other way around.
Choose fresh fruit or fresh fruit combinations to finish off a meal rather than the higher-calorie alternatives.
Sucking sweets or lollies or eating chocolates regularly makes it difficult to control your weight.
Some patients may go home with high blood sugar levels and may require insulin injections or tablets to control their blood sugar levels. If this is the case you will need to go on to a special diet to make it easier to control your blood sugar levels. Regular exercise also makes it easier to control your blood sugar levels.
The dietitian will discuss your diet details with you and your family prior to discharge. This will basically involve eating at regular intervals with an emphasis on reducing the amount of fat you eat and avoiding foods with a high concentration of sugar.
You may find that your blood sugar levels normalise within twelve months after transplantation and that you are then able to eat an unrestricted diet. Remember, that if this does happen then you still have the ability to gain weight easily.
Fluid retention may be a problem even by the time you go home. Avoiding added salt and food with an obviously high salt content would assist in controlling this excess fluid. Many patients may have been on a salt restriction prior to transplantation. It is not necessary to limit your salt intake as severely after your transplant.
As transplanted patients are immunosuppressed it is important to be aware of the possibility of food poisoning. There are two bacteria in particular which may be a serious problem for patients who may be immunosuppressed. They are Listeria monocytogenes and Vibrio vulnificans.
Vibrio vulnificans is a bacterium that may be present in raw shellfish. It is particularly harmful in people with a suppressed immune system. Although contamination with the bacteria is rare, all transplant patients are advised not to eat any raw shellfish.
Listeria monocytogenes is a bacterium that is more widespread in our food supply. It also loves to grow in the cold. Keeping foods in the refrigerator will not safeguard you from this “bug”. Careful handling of food and an awareness of possible contamination of specific foods will help prevent infection. You will receive a detailed brochure about this “bug” and its possible food sources from the dietitian when you have your transplant.
Finally, you always have access to the liver transplant dietitian. If you have any inquiries about your nutrition at any stage, you should not hesitate to contact the dietitian. Similarly if you are having difficulty controlling your weight at home after your transplant you should contact the dietitian earlier rather than later.
You can contact the dietitian through the Department of Nutrition and Dietetics - telephone number (02)9515 8053. Alternatively you can ask the staff at the Liver Transplant clinic to contact the dietitian.