Picture this scene…

You’ve got a cat on the way down. They’ve been a regular of yours for a while, for weight clinics. They’ve got an acute history of gastrointestinal signs, and haven’t eaten for a few days - and now they’re jaundiced, and pretty weak.

Are alarm bells ringing in your head, too? Yep - this smacks of hepatic lipidosis.

Hepatic lipidosis is the most common acquired liver disease we see in cats - and patients with hepatic lipidosis are usually very unwell, requiring intensive treatment and nursing care.

In today’s episode of the Medical Nursing Podcast, we’re breaking down exactly what hepatic lipidosis is, how it works, and how these patients are treated - as well as the nursing care they benefit from.

What is hepatic lipidosis?

Put simply, hepatic lipidosis is the accumulation of triglycerides (lipids) within the hepatocytes. As more and more lipid-containing vacuoles infiltrate the liver, hepatic function declines - and ultimately, liver failure results.

How does it happen?

Hepatic lipidosis can occur as either a primary or secondary condition, with approximately 95% of cases being secondary - to anything that causes anorexia. The most common underlying diseases include:

• GI disease

• Liver disease

• Pancreatitis

• FLUTD

• Endocrinopathies

• Renal disease

• Neoplasia

When a patient becomes anorexic, fatty acids are mobilised from fat stores within the body and converted into triglycerides by the liver (ketones are also formed as part of this process).

Normally, triglycerides would be converted to lipoproteins where sufficient proteins, amino acids and lipoprotein components are available. However, in an anorexic patient, these components aren’t necessarily there - meaning that, instead, the triglycerides accumulate in hepatocytes instead.

As more and more triglycerides accumulate in the liver, hepatic function becomes compromised, and continues to decline until hepatic failure results.

What signs do we see?

The main presenting sign is a history of anorexia or hyporexia for a period of days to weeks, resulting in sudden weight loss.

Alongside this, we can see:

• Intermittent vomiting

• Diarrhoea or constipation

• Dehydration

• Weakness

• Lethargy

• Poor skin/coat quality

• Jaundice

• Signs of hepatic encephalopathy

• Plus other signs depending on their underlying disease process, since HL is a secondary condition in most cases

On examination, we see marked weight loss, alongside evidence of jaundice, hepatomegaly and evidence of dehydration, and potentially neurological or musculoskeletal signs. Pain and nausea may be noted on examination - if the patient isn’t showing obvious signs of pain or nausea, however, it doesn’t mean it isn’t there!

How is it diagnosed?

Like other liver diseases, hepatic lipidosis is diagnosed via a combination of bloodwork (including biochemistry, haematology and electrolytes), urine analysis, diagnostic imaging (typically ultrasound) and hepatic sampling (FNA or biopsy).

Findings suggestive of hepatic lipidosis include:

• A markedly elevated ALP with a normal or near-normal GGT

• A mildly-moderately increased ALT

• Changes to liver function parameters

• A bright liver with increased fat deposits

• Highly vacuolated, lipid-dense cytoplasm on histology and cytology of the liver.
  

In addition to this, we can see other changes such as:

• Hypokalaemia

• Hypophosphataemia

• Poikilocytosis

• Neutrophilia

• Changes associated with the primary (underlying) disease process.

And how are we going to treat and nurse these patients?

So we’ve got our samples and we’re pending a diagnosis of hepatic lipidosis - with that, it’s time to talk about treatment!

And regardless of the underlying cause of our patient’s hepatic lipidosis, we’ll fundamentally be treating them the same way.

Goals of treatment

Our main goals of treatment are:

• To normalise fluid, electrolyte and acid-base disorders

• To provide early enteral nutrition, reversing the triglyceride accumulation

• To monitor for and manage any complications of the patient’s hepatic lipidosis, such as refeeding syndrome or hepatic encephalopathy

• To identify and treat the patient’s underlying disease process

We’ll be achieving these through the administration of intravenous fluid therapy at appropriate rates, alongside supplementation of things like potassium, magnesium and phosphate where needed (depending on the patient’s blood results).

Nutrition is the absolute cornerstone of treating hepatic lipidosis. Without feeding our patient, we won’t interrupt the cycle of fatty acid mobilisation and triglyceride accumulation. So we need to be prioritising feeding tube placement, and refeeding the patient carefully with a high-protein, moderate-fat, low-carbohydrate diet (assuming they don’t have hepatic encephalopathy).

On top of this, we’ll be reaching for supportive treatments including:

• Antiemetics

• Analgesia

• Antioxidants

• Vitamins E, B1, B12 and K

• Omega 3 fatty acids

• Amino acids

• Prokinetics

And how will we nurse these patients?

There is a lot for us to keep an eye on in patients with hepatic lipidosis, including vital signs, regular bodyweight assessment, respiratory pattern and effort, pulse quality and BP, alongside hydration and perfusion status, food and water intake, pain levels, and neurological status.

Next up is nutrition. We’ve already about how and what to feed, but as nurses and technicians, monitoring neurological status is an important consideration. We want to be regularly weighing these patients and re-assessing their food intake, BCS and MCS - tweaking their RER and feeding plan as needed to maintain bodyweight and avoid in-hospital weight loss.

Another important thing to consider is venous access. These patients often require lengthy treatment, regular blood draws and multiple medications - as long as there’s no coagulopathy, it could be worth considering a central venous catheter. Alternatively, a PICC line can be used - these are placed in peripheral vessels so a safer option in patients at risk of haemorrhage, but can still be used to collect repeated blood samples.

On top of this, we can’t overlook the importance of our general nursing care - monitoring eliminations and nausea, providing suitable cat-friendly accommodation and sticking to cat-friendly nursing considerations, and providing environmental enrichment and TLC.

So that’s an overview of our most common feline acquired liver disease - hepatic lipidosis! To sum up everything we’ve chatted about in this episode, hepatic lipidosis is usually seen secondarily to other diseases causing anorexia in cats. With prolonged anorexia, triglycerides accumulate in the liver causing hepatic dysfunction and ultimately hepatic failure. Early enteral nutrition is absolutely essential to recovery, so we need to place a feeding tube and refeed these patients very carefully, whilst providing supportive treatment and nursing care.

There are so many nursing skills these patients benefit from, including feeding tube placement, advanced vascular access and much more - and I hope this episode has helped you feel more confident at planning nursing care for your hepatic lipidosis patients.

Did you enjoy this episode? If so, I’d love to hear what you thought - screenshot it and tag me on instagram (@vetinternalmedicinenursing) so I can give you a shout out, and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Resources

1. Armstrong, PJ. 2011. Feline hepatic lipidosis: therapeutic considerations [Online] VIN. Available from https://www.vin.com/apputil/content/defaultadv1.aspx?pId=11343&meta=generic&catId=34572&id=5124420&ind=183&objTypeID=17

2. Center, SA. 2023. Feline hepatic lipidosis [Online] MSD Vet Manual. Available from https://www.msdvetmanual.com/digestive-system/hepatic-diseases-of-small-animals/feline-hepatic-lipidosis

3. Heinze, CR. 2020. Treatment of hepatic lipidosis in cats [Online] Tufts Veterinary Nutrition. Available from https://vetnutrition.tufts.edu/2020/11/hepatic-lipidosis-in-cats/

4. Merrill, L. 2012. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Iowa: Wiley-Blackwell

5. Nivy, R. 2023. Feline hepatic lipidosis [Online] VetFocus. Available from https://vetfocus.royalcanin.com/en/scientific/feline-hepatic-lipidosis