Enteral Energy and Macronutrients in End‐Stage Liver Disease

Abstract

Protein-energy malnutrition is the most common comorbidity affecting adults and children with end-stage liver disease. Despite clear evidence linking malnutrition to poor outcomes before and after liver transplantation, nutrition rehabilitation is often inadequately emphasized in the clinical management of these patients. The primary aim of this review is to synthesize the available evidence supporting the current clinical guidelines on enteral nutrition support and, more important, to highlight the lack of evidence behind much of what is considered "standard of care" for the nutrition management of patients with cirrhosis. In addition, the mechanisms of malnutrition are reviewed, the limitations of tools used to assess body composition in this setting are discussed, and the differences in macronutrient metabolism between healthy subjects and patients with end-stage liver disease are explained. A summary of recommendations is provided.

Nutrition Priorities: Diet Recommendations in Liver Cirrhosis

“…One pathophysiological reason to support protein from plant‐based and dairy sources is an increased intake of branched‐chain amino acids (BCAAs) found within these foods . Because of the changes in amino acid metabolism and insulin resistance in patients with cirrhosis, there is an imbalance of BCAAs available for protein synthesis in skeletal muscle . Increased intake of BCAA intake may improve appetite, increase muscle synthesis, and have an impact in improving quality of life .…”

Importance of malnutrition in patients with cirrhosis

“…Periods without oral intake in preparation for tests and procedures, unnecessary protein and calorie restrictions for the treatment of hepatic encephalopathy (HE), and medications account for some iatrogenic causes of poor oral intake. All of these factors may exist to varying degrees in patients with cirrhosis (8).…”

“…Bioelectrical impedance analysis is commonly used to estimate body composition; however, this method is also challenging owing to the prevalence of ascites or edema in this population (8,9,12). Serial measurements with a handgrip strength test have also been used in nutritional status evaluation.…”

“…However, carbohydrate restriction is not recommended for patients with cirrhosis, and they are advised to have frequent small meals and snacks to reduce the risk of hypoglycemia. Guidelines of ESPEN recommend that carbohydrates account for 45%-65% of the total daily calories, the same as for healthy adults (8,19 (3,6).…”

“…Unfortunately, BCAA preparations have important limitations: poor palatability, high cost, and lack of availability in Turkey (22,23). Moreover, alterations in lipid metabolism occur by several mechanisms, and guidelines suggest that fat should be provided at a minimum of 25%-30% of the total daily calories (8,19).…”