Archive for the Patient Category

Breathing Trouble

What is breathing trouble?

Breathing trouble describes discomfort when breathing and feeling as though you can’t get an entire breath. The medical term for shortness of breath is ‘dyspnea.’ It can come on suddenly or over weeks to months. It may occur when walking, climbing stairs, running or sitting still.

Symptoms of shortness of breath

Symptoms of shortness of breath can include:

  • Feeling like you have to work hard to breathe
  • Pain, discomfort or tightness in the chest
  • Fast breathing, heartbeat or both
  • Wheezing
  • Cough
  • Feeling panicked or anxious
  • Feeling lightheaded or even passing out
  • Swelling (edema) of your feet and ankles
  • Feeling breathless in the sitting or standing position and better when lying flat
  • Fingers/feet/lips turning blue (called cyanosis)

What causes shortness of breath?

Heart and lung conditions are common causes of shortness of breath. Your heart and lungs move oxygen throughout your body and remove carbon dioxide. Breathing is regulated by the brain. It is an interaction between chemicals in the blood and in the air that we breathe.

People who have advanced liver disease can have complications that affect the heart and lungs. Breathing problems can occur because you can’t take as big a breath due to:

  • A build-up of fluid in the belly (ascites). This buildup of fluid can compress the lungs and make it difficult to breath or take in deep breaths. The best way to improve your breathing is to get rid of the fluid (paracentesis) and take all medications prescribed by your doctor to manage ascites.
  •  A build-up of fluid between the tissues that line the lung and chest (pleural effusion)
  • A large spleen and liver that pushes the diaphragm up.

Things you can try to prevent and control shortness of breath:

  • Pace yourself
  • Trying not to hold your breath
  • Sit in front of a fan so it blows on your face
  • Sit upright. Using pillows to support your back may help
  • Maintain humidity in your room
  • Sit near an open window
  • Try meditation, mindfulness, or relaxation therapy

What are some relaxation techniques?

Some of your healthcare providers may be able to teach you relaxation techniques or you can learn some on your own. Some techniques include:

  • Progressive muscle relaxation (focus on slowly tensing and then relaxing each muscle group)
  • Visualization (form mental images to take a visual journey to a peaceful, calming place or situation)
  • Music and art therapy

 

Breathing problems and liver disease

Breathing problems can also occur with liver disease from changes in the blood vessels and blood flow in the lungs.

One problem that can develop with liver disease is portal hypertension. Portal hypertension refers to increased pressure in the blood vessel that enters the liver.

Liver disease and portal hypertension can cause problems in the blood vessels of the lungs. One factor that causes problems in the blood vessels of the lungs is the damaged liver’s inability to remove harmful substances from your digestive tract before they enter the rest of your body. These toxins can damage blood vessels in your lungs leading to larger or more narrow vessels. Two different conditions can be seen in the lungs that arise from liver disease:

Hepatopulmonary syndrome

Hepatopulmonary syndrome is a condition where the blood vessels in your lungs become enlarged, leading to low oxygen levels. Symptoms of hepatopulmonary syndrome are mostly caused by low oxygen levels in the blood. You may find yourself experiencing the following signs or symptoms:

■ Becoming short of breath easily

■ Feeling breathless in the sitting or standing position

■ Fingers/feet/lips turning blue (called cyanosis)

Diagnosis

There are three basic features required to make a diagnosis of hepatopulmonary syndrome:

■ low blood oxygen levels

■ enlarged blood vessels in the lungs

■ liver disease

You must have all three features to be diagnosed with hepatopulmonary syndrome. Your healthcare provider will usually order a sample of blood from an artery (arterial blood gas) test to evaluate your blood oxygen levels. Your healthcare provider may also order tests to look for enlarged blood vessels in your lungs.

Treatment

The only definitive treatment for hepatopulmonary syndrome is liver transplant. When liver transplant is not an option, there are limited medical therapies available.

Portopulmonary hypertension

Portopulmonary hypertension is a condition where the blood vessels in your lungs become narrowed, leading to increased blood pressure in the vessels of the lungs which obstructs the flow of blood through the lungs.

Symptoms

You may find yourself experiencing the following signs or symptoms:

■ Becoming short of breath or tired easily

■ Chest pain, which can be mistaken for a heart attack

■ Feel your heart pounding or racing

■ Feel lightheaded or even pass out

■ Swelling (edema) of your feet and ankles.

Diagnosis

The diagnosis of portopulmonary hypertension is made when you have increased lung (pulmonary) pressure and liver disease.

Treatment

Treatment of portopulmonary hypertension depends on the condition of your liver. Therapies can include:

  • medical therapy to widen the pulmonary blood vessels
  • liver transplant

Appetite Loss

Appetite Loss

If you are experiencing appetite loss you may eat less than usual, not feel hungry at all, or feel full after eating only a small amount. Having no appetite can lead to serious complications. These include weight loss, not getting nutrients your body needs, fatigue, and weakness from muscle loss. For those suffering from chronic diseases like cirrhosis, these issues can slow recovery and a decreased quality of life. It is important to talk to your healthcare provider (doctor, nurse practitioner, etc)  if  you lose your appetite. They can help you with making sure you are getting the nutrition you need. Your healthcare provider may also refer you to a dietitian, who are experts in food and nutrition.

Causes of appetite loss

Many different things can cause appetite loss in a person with cirrhosis, including:

  • A change in your metabolism due to your illness, which can also be complicated by different treatments, also known as ‘cachexia.’
  • Changes in metabolism, which is your body’s process of breaking down food and turning it into energy. Such changes can happen with cirrhosis.
  • Ascites, or a buildup of fluid in the belly, which can cause swelling, discomfort, and a feeling of fullness
  • An enlarged liver, which pushes on the stomach and creates a feeling of fullness
  • Medications
  • Surgery or procedures on parts of the gastrointestinal system
  • Side effects of cirrhosis treatments

Managing appetite loss

If possible, the first step in treating appetite loss is to address the cause. Treatment for side effects of cirrhosis treatments such as nausea, pain, or depression may help improve appetite.

Although you may not feel like eating, remember that getting good nutrition and keeping a healthy weight are important parts of your recovery.

Consider the following tips for getting proper nutrition when your appetite is low:

  • Eat smaller, more frequent high calorie meals each day (every 3 -4 hours)
  • Try to not drink a lot of fluids when you are eating so there is more room for food.
  • Determine which times of day you are hungry and eat at those times
  • Eat nutritious snacks that are high in calories and protein. Examples include dried fruits, nuts and nut butters, yogurt, cheese, eggs, cereal, and protein or granola bars.
  • Ask family members or friends to get groceries and prepare food for you when you are too tired to shop or cook. Also consider ordering precooked meals from a meal preparation company, such as Meals on Wheels. Many grocery stores also offer pick-up or delivery services.
  • Try to eat in pleasant surroundings and with family or friends
  • If the smell or taste of food makes you nauseous, eat food that is cold or at room temperature. This will decrease its odor and reduce its taste.
  • Try to reduce your intake of drinks like coffee, tea and water as they can decrease your appetite and do not have much nutrition
  • Sometimes, your health care team may use different interventions including placing feeding tubes. There are different types, see: What to Expect in the ICU

 

 

Health Benefits & Medication Coverage

The provincial and territorial governments are the primary administrators of healthcare and health benefits in Canada. Indigenous Albertans who have treaty status (as defined by the Indian Act) are able to receive health benefits through the Non-Insured Health Benefits (NIHB) program, which is administered federally. All Alberta residents (≥ 3 months of residency) are provided with basic medical coverage under the Alberta Health Care Insurance Plan (AHCIP).

People able to access extended health benefits (drug coverage, dental, ambulance, and optical) through various sources, including employer health benefits, provincial benefits, and federal health benefits (Indigenous peoples with status). Some provincial programs are means-tested (AAHB, ACHB, AISH/IS health benefits), and others base eligibility on other circumstances (Palliative Coverage, Coverage for Seniors). Non-Group Coverage is available for any Alberta resident under age 65 who applies.

Alberta Drug Benefit List

If you receive health benefits coverage through a provincial program (i.e. AISH, Income Support, Seniors Benefits, AAHB/ACHB, Blue Cross Non-Group) you can check the Alberta Drug Benefit List to see if a specific drug/health product is covered.
The Health Benefits Exception Committee reviews requests for drugs, optical, dental, ambulance services or diabetic supplies that are not covered in the optical agreements, dental agreements or drug benefit lists (i.e. restricted benefit). To submit a request for an exception, complete the Request for a Health Benefit Exception form and follow the instructions contained in the form.

Health Benefits Exception Committee

If your request is for drugs or nutritional products that are not covered on the drug benefit lists, your doctor must provide a detailed medical rationale using the Request for Prescription Drugs and Nutritional Products form.

If your request is for optical services that are not covered in the optical agreements, please have your optical services provider (ophthalmologist, optometrist, or optician) complete the Request for Optical Services form.

Health Benefit and Medication Coverage Programs

Alberta Adult Health Benefit (AAHB)

Alberta Health administers AAHB; however, Community and Social Services process enrolment in the program. AAHB is intended as a support to Albertans in low income to ensure they have access to prescription drugs, dental services, optical services, emergency ambulance and diabetic supplies that are essential to health and well-being.

The AAHB program is provided as an extension of health benefits offered through the Community and Income Support and AISH programs, to assist eligible persons leaving the programs to maintain employment.

The AAHB is also available to women during pregnancy and to households with high ongoing prescription drug needs, if their household incomes are within the AAHB qualifying income levels.

AAHB is a means-tested benefit. Eligible applicants may be: pregnant; have high ongoing prescription drug needs; refugee or refugee claimants not otherwise receiving health benefits from any other source; or leaving the Income Support or AISH programs due to excess income. People who would ordinarily not qualify for AAHB based on income, but have high drugs needs may qualify (total annual income – annual drug cost = adjusted income). If you have dependant children under the age of 18 and are low-income, see: Alberta Child Health Benefit for information.

Please note: Eligible applicants must have an annual household I not above qualifying levels. You must have completed your income tax return for the most recent year before applying. If your current annual income is lower than your last reported annual income, contact the Health Benefits Contact Centre.

To apply for AAHB, complete an application, and submit to Health Benefits Contact Centre by fax or mail. For assistance in completing your application, have your physician refer you to a social worker, or contact Alberta Supports.

Important Links

AAHB (All Information) 

AAHB Application

AAHB (What’s Covered)

Alberta Child Health Benefit (ACHB)

The Alberta Child Health Benefit (ACHB) covers children’s health expenses for families with low incomes. This health plan is for children up to 18 years of age. Children who are 18 or 19 years old also qualify, if they are living at home and attending high school. ACHB is a means-tested benefit. The total combined household net income plus non- taxable child support income received must be equal to or less than the applicable qualifying income level.

Please note: To be eligible for the ACHB, you and members of your family must be a low-income resident of Alberta, with an annual income below current threshold levels. You must have a Notice of Assessment (NOA) for the most current tax year in order to apply. If your current annual income is lower than your NOA, contact the Health Benefits Contact Centre for an exception.

To apply for ACHB, complete an application, and submit to Health Benefits Contact Centre by fax or mail. For assistance in completing your application, have your physician refer you to a social worker, or contact Alberta Supports.

Important Links

ACHB (All Information)

ACHB Eligibility

ACHB Application

Alberta Works (i.e. AISH, Income Support)

AISH and Income Support (BFE and ETW subtypes) are eligible to receive similar health benefit coverage provided for by the Alberta Adult Health Benefit (AAHB) and Alberta Child Health Benefit (ACHB) programs. People applying for AISH and Income Support will receive a health benefits card automatically upon the approval of their application.

Recipients of One-Time (Emergency) benefits through Income Support are able to access funds for up to one month of prescription medication, along with other emergency expenses.

Call the 24-hour Emergency Income Support Contact Centre (available 24/7):
Toll free: 1-866-644-5135 TTY toll free: 1-800-232-7215 (ask to speak to Alberta Supports) Fax: 780-422-9681 Email: [email protected] (responses may take 1-3 business days)

Give your pharmacy fax number and contact information to the Alberta Works worker you speak to. The worker will provide your pharmacist with a code valid for 24 hours in order for your prescription to be covered under emergency benefits.

Non-Group Coverage (Alberta Blue Cross)

The Non-Group Coverage program ensures all Albertans have access to an economical supplementary health benefits program. The program provides coverage for a variety of health-related services not covered by the Alberta Health Care Insurance Plan (AHCIP).
Alberta Blue Cross administers Non-Group Coverage on behalf of the Alberta government.

A monthly premium is charged for Non-Group Coverage. If your household income is too high to qualify for AAHB/ACHB, but falls under this threshold, you may be eligible to receive a subsidized premium for Non-Group Coverage.

Please note: This program does not provide travel coverage. If you are planning to travel outside of the province or country, you should purchase travel insurance to cover emergency hospital and medical expenses.

A $50 annual deductible is applied to the total of all eligible health benefit expenses incurred in a benefit year, except for prescription drugs and diabetic supplies. The benefit year runs from July 1 to June 30. When no claim has been made for health benefits in a benefit year, any such expenses incurred during April, May or June that do not exceed $50 may be carried forward into the next benefit year and credited, in whole or in part, toward the deductible in that year.

For prescription drugs, the co-payment is 30% to a maximum of $25. A co-payment is the portion of the prescription cost you pay to your pharmacy when you have your prescription filled. For most prescriptions, you will not pay more than $25 for each prescription. Prescription drugs covered under the plan are listed in the Alberta Drug Benefit List.

Benefits include diabetic supplies, ambulance services, clinical psychological services, home nursing care, prosthetic and orthotic benefits, mastectomy prosthesis, and hospital accommodation (semi-private).

These benefits include an annual maximum, and are subject to a $50 annual deductible (total per annum). Prescription medications are not subject to this deductible (see above).

 

Important Links

Non-Group Coverage (All Information)

Eligibility for Monthly Premium Subsidy 

Non-Group Coverage Application

Coverage for Seniors (Alberta Blue Cross)

Seniors, their spouses/interdependent partners and dependants registered on the same Alberta Health Care Insurance Plan (AHCIP) account receive a premium-free benefit to provide coverage for prescriptions and other health-related services not covered under the AHCIP.

Alberta Blue Cross administers the Coverage for Seniors program and claims. AHCIP manages eligibility and registration.

Please note: This program does not provide travel coverage. If you are planning to travel outside of the province or country, you should purchase travel insurance to cover emergency hospital and medical expenses.

To be eligible for Coverage for Seniors, you must provide proof of being 65 years of age or older. When AHCIP records indicate an Albertan will be turning 65, a package is mailed to the address on their AHCIP file providing information about programs and services for seniors. This package will include a letter asking you to submit proof-of-age documents if required. If you did not receive the package, or have further questions, contact the AHCIP office.

If AHCIP have a proof-of-age document on your AHCIP file, Coverage for Seniors is automatically added to your AHCIP account. If you are unsure if you are already covered, call Health Link (811) with your AHCIP number ready to inquire.

If AHCIP does not have a proof-of-age document on your AHCIP file, you will need to submit a proof-of-age document and a completed Proof-of-Age Declaration form.

Acceptable proof-of-age documents include: birth certificate, old-age pension entitlement form, passport or immigration record, or Canadian citizenship certificate.
Take your proof-of-age document and declaration to an AHCIP authorized registry agent for processing. You can also mail the completed form and a copy (both sides) of the proof-of-age document to the AHCIP office.

Low-income seniors may qualify for additional funding for medical supplies and equipment through SNA-Seniors, including a portion of prescription drug co-payments.

Important Links

Coverage for Seniors (All Information)

Coverage for Seniors Benefit Information

 

Palliative Coverage (Alberta Blue Cross)

The Palliative Coverage Program provides subsidized benefits to Albertans who are diagnosed as palliative and remain in their home or in a hospice where access to publicly funded drugs, diabetic supplies, and ambulance services are not included.

Albertans who are palliative are provided access to supplementary health benefits that provide coverage for health-related services not covered by the Alberta Health Care Insurance Plan (AHCIP) through this program.

Alberta Blue Cross administers the Palliative Coverage program. There are no premiums to pay. The program is open to Albertans registered with the AHCIP and who have been diagnosed as being palliative.

Palliative refers to patients who have been diagnosed by a physician or nurse practitioner as being in the end stage of a terminal illness or disease. Patients are aware of their diagnosis and have made a voluntary informed decision related to resuscitation, and the focus of care is palliation and not treatment aimed at a cure.

Please note: The program excludes patients who live in residences that provide publicly funded drugs, diabetic supplies and ambulance service, including long-term care facilities, acute care hospitals, and psychiatric hospitals.

To apply for the Palliative Coverage Program, download and complete the application form. The application form must be completed and signed by both the affected patient, or guardian, and physician or nurse practitioner.

The patient or guardian will receive written notification from the Ministry of Health regarding acceptance into the program. Alberta Blue Cross will mail an ID card to the patient or guardian.

The physician or nurse practitioner determines the effective date of coverage. This date must not be more than 30 days prior to the date the program office receives the application. The coverage will continue if the patient is diagnosed as being palliative.
This program covers prescription medications, specific laxatives and solutions for hydration therapy are covered if listed in the Alberta Drug Benefit List or Palliative Care Drug Benefit Supplement. You will be responsible for 30% of the cost of the prescription to a maximum of $25 co-payment, and a lifetime maximum of $1,000.

Please note: You may be responsible for additional costs if: your drug is not listed in the Alberta Drug Benefit List; or you want a more expensive brand of drug than the lowest- cost option, maximum allowable cost product, or generic product; or the brand of drug you want costs more than the maximum amount set by the Alberta government for that drug.

 

Important Links

Palliative Coverage (All Information)

Palliative Coverage Application

How to Claim Benefits though Alberta Blue Cross

Non-Insured Health Benefits (NIHB)

The Non-Insured Health Benefits (NIHB) Program of the Department of Indigenous Services Canada provides eligible clients (persons with registered First Nations status and recognized Inuit) with coverage for a range of health benefits, including prescription drugs and over-the-counter medications, dental and vision care, medical supplies and equipment, mental health counselling, and transportation to access health services not available locally.

These benefits complement ACHIP coverage, which includes physician and hospital care, as well as other First Nations-oriented community programs and services. For low-income Albertans with First Nations status, you can access benefits not covered by NIHB through different provincial benefit programs (i.e. AISH, Income Support, AAHB). If you experience difficulty obtaining coverage due to the coordination of these benefits, ask a social worker to assist you.

Benefits include drugs, medical transportation, dental care, medical supplies and equipment, crisis intervention counselling and vision care.

If you require assistance with accessing benefits, have inquiries about coverage, or any other questions, contact your band worker or have a social worker assist you in contacting NIHB.

 

Important Links

NIHB Contact Information

NIHB Client Reimbursement Form

NIHB Eligibility

NIHB Guides

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

    1. US Department of Veterans Affairs, Veterans Health Administration 
    2. Canadian Liver Foundation
    3. Ministry of Community and Social Services Alberta 
    4. Department of Indigenous Services Canada 
Last reviewed March 15, 2021

Medication Safety

Most medicines are processed through the liver and kidneys. So, it’s important to think about safety when you are taking medicine, especially when you have liver or kidney disease.

Know the names of your medicines and what they are used for. Bring a list of them and the doses to appointments with your healthcare team. Without this information, it will be difficult and possibly even unsafe to make changes in your treatment.

Always take your medicine as prescribed and let your health care team know if you are taking over-the-counter or herbal medicines. If you are not sure if something is safe, please ask a member of your healthcare team, like your pharmacist.

Below you can find information for people with cirrhosis, on some common medications.

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (or NSAIDs) are medicines used to treat pain. Some examples of NSAIDs are ibuprofen, Motrin, Advil, Naproxen and Aleve. You should avoid NSAIDs if you have cirrhosis, especially if you have problems with ascites or fluid build-up. They can cause serious problems with your kidneys and increase your risk of bleeding.

Acetaminophen (Tylenol®)

If you have cirrhosis, you may have been told not to take acetaminophen. But, you actually can as long as you keep the dose to less than 2000 milligrams a day and don’t drink alcohol. You can take up to 4 extra strength acetaminophen in a day, as long as they only have 500mg in each pill. You should always read the medicine label. If you follow these guidelines, acetaminophen is actually safer than most other pain medicines.

Opioids

Narcotics and opioids are usually used to treat pain. Some examples are codeine, morphine and fentanyl. Taking these medicines when you have cirrhosis is complicated, and can be dangerous, and it’s best to avoid them.

Sedatives

Benzodiazepines are a type of medicine used to treat anxiety. Some examples are Ativan or valium. They can make you feel really sleepy if you have cirrhosis. It’s best to avoid them or take them as little as possible. Even over-the-counter medicines like Benadryl, which is used for itching and allergies, or Gravol, for nausea, can cause too much sleepiness. If you need to take these medicines, try taking a lower dose for a limited period of time.

Cold and Flu Medications

Many over the counter medicines for colds and flus contain more than one drug. Some contain NSAIDs, which you shouldn’t take. Others have decongestants and antihistamines that can make you drowsy. Remember to read medication labels so you know what’s in them before you take them.

Herbal Medicines

The small amounts of herbs used in cooking don’t usually cause health problems. But, herbal medicines can be risky, because they contain more concentrated and larger amounts of herbs.

Milk thistle is a common herbal medicine that people with liver disease might be interested in. Studies haven’t proved that it helps the liver, but it’s generally considered safe, although it can have side effects like diarrhea and bloating.

Remember that just because something is “natural” doesn’t mean it’s safe. Most herbal medicines have not been studied in people with cirrhosis, and some have been found to be toxic for the liver.  Also, herbal medicines can interact with other medications you’re taking.

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021

Alcohol

Anyone with liver disease should NOT drink alcohol. 

Alcohol affects everyone. When a person has a drink, the alcohol is absorbed through the wall of the stomach and intestine into the bloodstream, where it is sent throughout the body. Alcohol affects the brain, heart, muscles and other tissues of the body.

Age, gender, body weight, and genetic factors can all affect the way alcohol is processed by the body. For example, women absorb more alcohol from each drink than men do and tend to be more susceptible to alcohol-related liver damage.

The liver filters and processes everything a person ingests, including alcohol. If the liver is damaged, even small amounts of alcohol can make things worse.

Finding it hard to avoid alcohol?

Cutting down or stopping drinking may be difficult at times. Most people do not cut down or give it up all at once. Just like going on a diet, it is not easy. That’s OK. If you don’t reach your goal the first time, try again. Get support from people who care about you and want to help. Don’t give up!

Drinking Diary 

To keep track of how much you drink, use a drinking diary. Record the number of drinks you have each day. At the end of the month, add up the number of drinks you had each week.

Change Plan

One way to make any kind of change in your behavior is to come up with achange plan.” This exercise has you list the specific goals you would like to achieve, outline the steps and challenges you will meet in reaching those goals, and figure out ways to overcome those challenges.

Helpful Tips
  • Keep no alcohol, or only a small amount at home.
  • If you drink, sip your drink slowly. Take a break of 1 hour between drinks. Drink water or non-alcoholic drinks after a drink with alcohol. Do not drink on an empty stomach! Eat food when you are drinking.
  • If you drink, pick a day or two each week when you will not drink at all. Then, try to stop drinking for 1 week. Think about how you feel physically and emotionally on these days. When you succeed and feel better, you may find it easier to cut down for good.
  • You do not have to drink when other people drink. You do not have to take a drink that is given to you. Practice ways to say no politely. For example, you can tell people you feel better when you drink less. Stay away from people who give you a hard time about not drinking.
  • Watch out for people, places, or times that make you want to drink, even if you do not want to.
  • Stay away from people who drink a lot and avoid bars where you used to go.
  • Plan ahead of time what you will do to avoid drinking when you are tempted.
  • Don’t drink when you are angry or upset or have a bad day. These are habits you need to break if you want to drink less.
  • What would you do instead of drinking? Use the time and money spent on drinking to do something fun with your family or friends. Go out to eat, see a movie, or go for a walk.

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021

Stress Management

Everyone can benefit from learning ways to manage stress. This includes people with chronic medical conditions, like cirrhosis. My Health Alberta has excellent information and videos on stress management. If you want to learn more about stress management, we recommend you access the resources by going to MyHealth.Alberta.ca or by clicking on the links below:

 

Cirrhosis Nutrition Info

People with cirrhosis need more protein and calories than the average person. If your liver is not working well, you may become tired and weak. Eating enough protein and calories is important if you have cirrhosis because:

  • your liver may be working harder than usual
  • you may not be able to store as many nutrients as usual

The information on this page can help you get the nutrition (protein, calories, vitamins, and minerals) you need to stay strong and be able to do the things you need to do every day. It will also help you cut down on the salt (sodium) you eat.

When to Eat

Some people with cirrhosis can find eating quite challenging. Lack of hunger, fluid build-up, and nausea are just some examples of things that may impact your ability to eat. You can improve your food intact by making sure you eat:

  • breakfast soon after you wake up
  • every 3 to 4 hours during the day
  • a snack before bed, and again if you wake in the night

Protein

Everyone needs a different amount of protein. Talk to your healthcare provider about how much is right for you. Start by eating 3 meals and 2–3 snacks each day. Have a bedtime snack every day

Protein in foods

Use the Protein in foods table below to choose:

  • at least 2–3 servings of protein at each meal, and
  • at least 1–2 servings of protein at each snack.

Protein in foods
Food 1 serving
Milk products
Milk, kefir, chocolate milk 1 cup (250 mL)

Regular yogurt 3/4 cup (175 mL)

Greek yogurt 1/4 cup (60 mL)

Cheese * 1 0z (30g)

Ricotta or cottage cheese* 1/4 cup (60 mL)

Plant-based protein foods
Hemp seed hearts 2 Tbsp (30 mL)

Nuts and seeds, unsalted 1/4 cup (60 mL)

Nut and seed butters, unsalted 2 Tbsp (30 mL)

Meatless protein, vegetarian ground round 2 Tbsp (30 mL)

Peas, beans, lentils, soft tofu 1/2 cup (125 mL)

Hummus, soybeans (edamame) 1/3 cup (75 mL)

Tempeh 1/4 cup (60 mL)

Firm tofu 1/3 cup (3.5 oz/100g)

Soy beverage** 1 cup (250 mL)

Bread, whole grain 1 slice

Animal protein foods
Fish, chicken turkey, pork, beef, game meats (cooked) 1 oz (30 g)

Eggs 1

Egg whites 2 whites, 1/4 cup (60 mL)

Nutrition supplements
Nutrition supplement drinks, bars, pudding
Protein powders

Protein bars, shakes
Protein amounts vary. Read nutrition Facts tables on packages.

Meals higher in protein
  • Add beans or lentils to soups, stews, and sauces.
  • Melt low salt cheese in soups, sauces, scrambled eggs, and casseroles.
  • Have cereal with 1 cup of milk at breakfast.
Snacks higher in protein
  • Add protein powder to hot cereal, smoothies, pudding, and homemade muffins.
  • Add unsalted nuts, seeds, and wheat germ to cereals, salads, smoothies, or yogurt.
  • Toast with 2 Tbsp (30 mL) peanut butter.
  • A muffin with cheese
  • Fruit and a container of Greek yogurt
  • A smoothie: banana, milk, protein powder.
  • Have a nutrition supplement drink.

Talk to your healthcare team about other ways to increase the protein in your diet.

Take a look at this handout for more information about protein and cirrhosis: Eating well with cirrhosis

Sodium (Salt)

Too much sodium can make your body hold on to extra fluid. This fluid can pool in your belly and legs. Swelling in your belly (ascites) can make you feel fuller, quicker. Eating foods with less sodium can help control ascites.

  • Aim to eat less than 2000 mg of sodium a day.
  • One teaspoon of salt has about 2300 mg of sodium.
  • All types of salt contain the same amount of sodium, including table salt, sea salt, and Himalayan salt.
Tips to reduce sodium:
  • At first, foods may taste bland. Over time, your taste buds get used to less salt.
  • Don’t add salt to your food while cooking or at the table.
  • Choose fresh, unprocessed, and homemade foods.
  • Eat less processed, packaged, or restaurant foods.
  • Limit condiments and sauces (ketchup, mustard, soy sauce, gravies, salad dressings).
  • Limit pickled foods, olives, chutneys, and dips.
  • To boost flavours, try adding spices, seasoning mixes with no salt added, lemon, lime, vinegar, fresh or dry herbs, garlic, or onions

Learn to read food labels

Vitamins and Supplements

People with cirrhosis can be low in some vitamins and minerals. Osteoporosis (weak bones) is common in liver disease. Getting enough vitamin D and calcium will help keep your bones strong.

  • Every day, take a multivitamin and mineral pill with no iron.
  • You may be asked to take calcium or vitamin D pills.
  • Talk to your healthcare team about what kind of supplement is right for you
  • There are many complementary and alternative medicines that are available that claim to ease the symptoms of liver disease or to reduce your risk of developing liver disease. Most of these medicines are processed by the liver, and can be very dangerous to people with liver problems. To learn more about these medicines, Click Here. 

The Importance of Nutrition to Prevent and Treat Low Muscle Mass

The Nutrition in Cirrhosis Guide

Our national team of healthcare practitioners specializing in cirrhosis developed a practical “nutrition tool” for patients. With our patients, this became “The Nutrition in Cirrhosis Guide” – intended for patients as well as their family and friends.

For personalized nutrition assistance, ask your doctor or get a referral to a registered dietitian. Both types of healthcare practitioners can provide personalized nutrition goals and help you reach them.
To download the complete “Nutrition in Cirrhosis Guide” (40 pages) as a .pdf file, click here.

The Guide was made possible from extensive feedback from patients, and their family & friends, who attend The Cirrhosis Care Clinic (TCCC) at the University of Alberta in Edmonton, Alberta, Canada.

Funding for the Guide’s creation was obtained from a research grant from the Canadian Institutes of Health Research (CIHR) and Alberta Innovates. Alberta Health Services provided protected time to V DenHeyer.

The following organizations provided support in the form of unrestricted educational grants to support the Guide:

Peer review regarding the content and format of the Guide was obtained from registered dietitians (RDs) and gastroenterologists in Halifax, Montreal, Toronto, Edmonton, Calgary, and Vancouver. Additional input was obtained from experts across North America and Europe. Thank you for your valuable input and assistance.

If any portion of the Guide is used in research, communications, or patient care, please use the following citation:

Tandon P, DenHeyer V, Ismond KP, Kowalczewski J, Raman M, Eslamparast T, Bémeur C, Rose C. The Nutrition in Cirrhosis Guide. University of Alberta, Edmonton, Alberta. 2018. pp. 1- 40.

The Nutrition in Cirrhosis Guide may be reproduced for non-commercial use as is and in its entirety without further permission. Adaptations, modifications, unofficial translations, and/or commercial use of The Nutrition in Cirrhosis Guide are strictly prohibited without prior permission.

Chapter 1 – Malnutrition

 

 

 

This chapter covers the following topics:

  • What is malnutrition?
  • Warning signs of malnutrition
  • Who is at-risk for malnutrition?
  • Why are patients with cirrhosis so susceptible?

 

 

Who will benefit from reading this chapter?

  • Any Patient with Cirrhosis
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 2 – What to eat and what to avoid?

 

This chapter covers the following topics:

  • What foods to avoid eating?  Which foods are good for the liver?
  • BMI Calculator (Body Mass Index)
  • Daily calorie intake - what is it and why it is important
  • Important nutrients: protein & sodium
  • How and why it's important to track body weight

Who will benefit from this chapter?

  • Any Patient with Cirrhosis
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 3 - Tips for eating even when not hungry

 

 

This chapter includes the following topics:

  • How to manage fatigue, cooking, and eating
  • How to cope when getting full after just a few bites
  • Smart tips for stretching the food budget
  • How to stick to a regular eating schedule

 

Who will benefit from reading this chapter?

  • Any Patient with Cirrhosis
  • Anyone who prepares food for person living with cirrhosis
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 4 – Recipes

 

This chapter includes liver-friendly recipes that are:

  • Nutritious
  • Easy to prepare & use inexpensive ingredients
  • Modifiable to accommodate dietary restrictions, tastes & preferences
  • Weight maintenance & weight loss friendly
  • Suitable for those with & without cirrhosis
Some recipe examples are:
  • Baked Chicken Dinner
  • Salmon Salad
  • Homemade Banana Muffins - YUM!
  • Black Bean Soup

 

Who will benefit from reading this chapter?

  • Anyone cooking for a Patient with Cirrhosis
  • Any Patient with Cirrhosis
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
  • Anyone looking for easy-to-make, nutritious & delicious recipes!
Chapter 5 – Meal supplements

 

This chapter includes topics about:

  • When are meal supplements useful?
  • Common meal supplement drinks
  • Which supplement drinks are best for which health conditions

 

 

Who will benefit from this chapter?

  • Any Patient with Cirrhosis with a poor appetite or needing snack ideas
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 6 - Managing weight loss & cirrhosis

This chapter includes sections on:

  • Diet priorities for non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH)
  • Protein intake - it's a priority!
  • Tips for reaching daily protein targets
  • Eating to help the liver & lose weight at the same time - Help?

 

Who will benefit from this chapter?

  • All Patients with NAFLD, NASH, or cirrhosis caused by NAFLD or NASH
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners
Chapter 7 - What to expect in the hospital

 

This chapter includes topics about:

  • What meals and snacks to expect
  • I can't follow my usual eating schedule - Help?
  • What is a "nasogastric (NG) feed"
  • Why an NG may be prescribed

 

 

Who will benefit from reading this chapter?

  • Any Patient with Cirrhosis who is being admitted to the hospital
  • Caregivers
  • Family & Friends
  • Physicians & Other Healthcare Practitioners

For more information, check out the Eating Well With Cirrhosis handout!

Eating well in hospital

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021

Vaccinations

Having cirrhosis can make your immune system weaker and put you at higher risk of getting sick from viruses.

Vaccines can help lower your risk.

Below you can find information about some common vaccines you can consider. Ask your health care team which vaccines are right for you and how you can access them in your community.

COVID-19

Local availability and prioritization policies will affect when you may be eligible to receive the COVID-19 vaccine. People with cirrhosis should get the first COVID vaccine they are eligible for. If you have had infection or fever, you should wait to get vaccine until you are recovered.

For more information COVID-19 vaccine click here.

Until more data is available, below are some liver related COVID-19 vaccine recommendations. These are general, and may not apply to your specific health situation. Talk to your healthcare team to find out what is recommended for you.

Hepatitis B or C

If you are taking antiviral medications for Hepatitis B or C, you should NOT stop these medications while getting COVID-19 vaccines.

PBC and Autoimmune Hepatitis

If you take medication for primary biliary cholangitis (PBC) or autoimmune hepatitis, you should NOT stop these medications while getting COVID-19 vaccines.

Hepatocellular Carcinoma (HCC)

If you are being treated for HCC with ablation, embolization or chemotherapy, you should still be considered for COVID-19 vaccines without having to stop your HCC treatment

Liver Transplant Candidates

If you are waiting for liver transplant, you should get the COVID-19 vaccine, with the final dose given at least 1-2 weeks before transplant if possible.

Because liver transplant is considered a life-saving procedure, if you are offered a liver from a deceased donor, you should NOT delay your transplant because you recently received a COVID-19 vaccine.

Living Liver Donors

If you are wishing to donate part of your liver (live liver donor), you should get a COVID-19 vaccine. Your second dose should be at least two weeks before the transplant surgery if possible.

Liver Transplant Recipients

Always talk to your transplant team about COVID vaccine and your specific situation. Until more data is available, below are some considerations:

  • If you have received a liver transplant, COVID-19 vaccination is recommended for you.
  • Wait at least 1 month after transplant before getting the vaccine. 
  • Wait at least 1-month after treatment of rejection before getting the vaccine.
  • If you have had COVID, wait until your symptoms are gone and you are no longer considered infectious prior to vaccination.
  • Wait for a period of at least 2 weeks after the administration of another vaccine.
  • Your anti-rejection medications should NOT be lowered for the purpose of trying to increase your immune response to the vaccine.
  • If you are due for a second dose of vaccine right after your transplant, the second dose can be delayed to when will likely have a better immune response.
  • Your household contacts should be vaccinated whenever possible.

 Based on the AASLD Expert Panel Consensus Statement on Vaccines to Prevent COVID-19 Infection in Patients with Liver Disease

Influenza vaccine

If you have cirrhosis, you should get the influenza vaccine each year (usually available in the fall), to protect you against influenza viruses. This can usually be arranged through your family doctor or the public health clinic in your community. For more information, visit the links below:

What Difference Could the Flu Shot Make?

Influenza (FLU) vaccine

Common questions about influenza immunization

Pneumococcal Vaccine (Pneumovax)

If you have cirrhosis, you should get the pneumococcal vaccine to protect you against pneumococcal diseases. This can usually be arranged through your family doctor or the public health clinic in your community. For more information, visit the links below:

Pneumococcal Polysaccharide Vaccine FAQs

Pneumococcal polysaccharide (PNEUMO-P) vaccine

Hepatitis A & B Vaccines (Twinrix, Havrix)

Hepatitis A & B are viruses that can damage your liver. If you have cirrhosis, you should get vaccines to protect you against these viruses. This can usually be arranged through your family doctor or the public health clinic in your community. For more information, visit the links below:

Hepatitis A and B (HABV) vaccine

References:

The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.

References: 

  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021