Protein Recommendations for Older Adults with Cirrhosis: A Review

Abstract

Protein intake has a key role in liver cirrhosis in older adults. However, types and amounts of protein intake in cirrhosis have been controversial. The aim of this paper is to investigate the optimal protein intake for management of cirrhosis and prevention of hepatic encephalopathy in older adults. Protein restriction of 0.6 g/kg/d has traditionally been used as medical nutrition therapy in liver cirrhosis. However, recent evidence has shown that protein restrictions have many negative consequences for older adults with cirrhosis. Current research indicates protein intakes of 1.2-1.5 g/ kg/d in liver cirrhosis; however, many older adults do not consume this amount. Strategies to help increase protein intake and manage cirrhosis include ensuring adequate protein at every meal through either regular intake or supplementation, protein supplementation prior to bedtime or overnight, and supplementation with branchedchain amino acids. An emphasis on vegetable protein versus animal protein is probably not an advantageous treatment option because of lack of conclusive evidence regarding benefits and potential negative side effects. and progression of chronic liver disease and cirrhosis.There are several different factors that naturally occur in older adulthood that help contribute to the development of chronic liver disease and cirrhosis. After reaching maximum size in early adulthood, the liver steadily decreases in both size and the amount of blood flow it receives, leading to decreased function and efficiency over time [10] . Also, increased ammonia production and bacterial overgrowth are common in older adulthood, both of which are thought to play a key role in development of hepatic encephalopathy [11] . Older adults tend to have chronic constipation, intestinal dysmotility, and increased colonic transit time, which predisposes them to increased ammonia production [12] . Finally, older adulthood is associated with a higher incidence of diabetes, which is strongly correlated to progression of liver cirrhosis [13] . Pathogenesis of malnutrition in older adults with cirrhosisIt is estimated that 20% of patients with compensated cirrhosis and 60% of patients with decompensated cirrhosis have malnutrition [14] . In older adults, protein energy malnutrition is associated with high health care costs, increased frequency of infection and bedsores, increased morbidity and mortality, and poor physical functioning [4,5] . In canine trials, poor nutritional status has been shown to encourage the development of hepatic encephalopathy [15] . In addition, malnutrition in cirrhosis is positively associated with old age [14] . Multiple factors help contribute to the development of malnutrition in older adults with cirrhosis, including inadequate intake, altered absorption, sarcopenia, and altered metabolism. All causes must be explored and taken into consideration when developing treatment and prevention strategies.In older adults, food intake naturally decreases over time [16] , which promotes the development of malnutri...

A narrative review of nutritional abnormalities, complications, and optimization in the cirrhotic patient

“…Factors such as early satiety due to ascites, fluctuations in ghrelin and leptin, salt-restricted and protein-restricted diets, and nausea and vomiting can contribute to diminished food consumption (2)(3)(4)(5). This is of particular consequence to older patients, as it is known that oral intake decreases with increased age (2). In addition to reduced consumption of amino acid building blocks, cirrhotic patients lose the capacity to maintain proper homeostatic balance of protein metabolism.…”

“…In addition to reduced consumption of amino acid building blocks, cirrhotic patients lose the capacity to maintain proper homeostatic balance of protein metabolism. That is, the liver's protein synthetic function and amino acid modification is greatly impaired (2). Furthermore, disturbances of metabolism of other macronutrients, particularly fat malabsorption and glycogen storage abnormalities, insulin resistance, and increased adrenergic activity leads to increased gluconeogenesis powered by amino acids sourced increased breakdown and catabolism of protein (5,6).…”

“…Abnormalities of protein metabolism, specifically increased catabolism in relation to anabolism, result in sarcopenia, or muscle mass depletion (2,3,5,6,32). Sarcopenia is a common complication of cirrhosis, with a mean occurrence of 48% (ascertained from a metanalysis of 20 studies involving 4,037 patients); other literature dictates a prevalence range of 40-70% (32,33).…”