The nutritional management of hepatic encephalopathy in... : Hepatology (original) (raw)

Liver Failure/Cirrhosis/Portal Hypertension

The nutritional management of hepatic encephalopathy in patients with cirrhosis: International society for hepatic encephalopathy and nitrogen metabolism consensus

Amodio, Piero1; Bemeur, Chantal2; Butterworth, Roger3; Cordoba, Juan4; Kato, Akinobu5; Montagnese, Sara1; Uribe, Misael6; Vilstrup, Hendrik7; Morgan, Marsha Y.8

1_Department of Medicine University Hospital of Padua Padova Italy_

2_Department of Nutrition University of Montreal Montreal Quebec Canada_

3_Neuroscience Research Unit, Centre Hospitalier de l'Universitè de Montrèal Montreal Quebec Canada_

4_Liver Unit Hospital Vall Hebron, Universitat Autánoma de Barcelona Barcelona Spain_

5_Division of Gastroenterology and Hepatology, Department of Internal Medicine Iwate Medical University Morioka Japan_

6_National Institute of Nutrition and Medica Sur Clinic and Foundation, National University of Mexico Mexico City Mexico_

7_Department of Medicine V Aarhus University Hospitral Aarhus Denmark_

8_UCL Institute for Liver and Digestive Health, Department of Medicine, Royal Free Campus University College London Medical School, University College London London UK_

Received April 4, 2012; accepted February 25, 2013.

Address reprint requests to: Piero Amodio, M.D., Department of Medicine, University Hospital of Padua, Via Giustiniani 2, 35128 Padova, Italy. Email:[email protected]; fax: +390497960903.

Potential conflict of interest: Nothing to report.

Abstract

Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly. Conclusion: Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE. (Hepatology 2013)