Effect of dietary protein manipulation in subclinical portal-systemic encephalopathy.

Abstract

SUMMARY Eight stable cirrhotic patients with mild or subclinical portal-systemic encephalopathy (PSE) were studied after shunt surgery when they were off all antiencephalopathic therapy. Equal amounts of mixed proteins were alternated with animal or vegetable protein in a crossover protocol under metabolic conditions for five consecutive, one week periods. The different dietary periods were not associated with either a change in the neurological impairment score or the Trailmaking Tests, which showed a learning effect. The peak frequencies of the computer analysed EEG (CAEEG) were lower during the animal (6.58±0.42 Hz) than the vegetable (7.10±0.44 Hz) diet (p 0.01). Neither arterial ammonia levels nor plasma amino acid ratios changed with the diets, whereas urinary 3-methyl-histidine excretion increased during the animal diet. During the vegetable diet the apparent nitrogen balance tended to be more positive than during either the mixed or animal diets associated with a decrease in the urinary nitrogen excretion. The peak frequency of the CAEEG is the most sensitive test to monitor methods of treatment in portal-systemic encephalopathy. A vegetable protein diet, rather than overall protein restriction, should be considered in the management of this disorder, particularly when the nutritional state is poor.Treatment of mild portal-systemic encephalopathy focuses on prevention of symptoms by protein restriction and, if necessary, by adding lactulose or neomycin. Recently Greenberger1 showed that not only the quantity but also the quality of the dietary protein may be important in the management of the chronic condition. Vegetable derived protein was claimed to be superior to animal protein. Only three patients were studied, however, and two received additional anti-encephalopathic treatment with neomycin, lactulose, or sorbitol. Furthermore, the protocol of the protein administration varied.To investigate the role of dietary protein in portal-systemic encephalopathy we undertook a controlled trial with elimination of all variables apart from the source of protein in the diet. The ' Present address: Karel M de Bruijn, Helpersoon 125, 9722 B7,

Lactulose improves cognitive functions and health-related quality of life in patients with cirrhosis who have minimal hepatic encephalopathy

“…Several lines of evidence suggest that the pathogenesis of MHE is similar to that of overt HE. [15][16][17] Several treatment modalities that reduce ammonia level have been tried in order to treat this condition, for example, dietary protein manipulation, 18 branched-chain amino acids, 19 L-ornithine L-aspartate, 20 lactulose, 21,22,46 and probiotics. 23 Most of the studies of these treatment modalities have found improvement in psychometry, [19][20][21][22][23] ammonia level, 20,23,24 and cerebral edema.…”

“…[15][16][17] Therapeutic interventions that aim to reduce ammonia are also useful in this setting. [18][19][20][21][22][23][24] Most studies have shown improvement in psychomotor functions coupled with a reduction in ammonia level. Improvement in cognitive functions may translate into improvement in HRQOL.…”

Protein Recommendations for Older Adults with Cirrhosis: A Review

“…In a short-term bed rest study, healthy older men were given a protein supplement of 20 g after breakfast and before sleep versus no supplement. Results movements, EEG improvements, a trend toward positive nitrogen balance, improved branched-chain amino acid to aromatic amino acid ratio, lower urine nitrogen concentrations, and lower plasma ammonia levels [36,37,41,[52][53][54] . One of the studies showed no significant differences in grade of HE, nitrogen balance, or plasma amino acids [55] .…”

“…To date, only 7 studies have been completed that examined vegetable protein versus animal protein and their effects on hepatic encephalopathy [36,37,41,[52][53][54][55] . Six of the studies showed positive results on vegetable protein, including improved HE, improved mental status, larger bowel across daily meals, whereas frail and prefrail individuals tend to skew their protein intake toward noon meal while consuming significantly less at other meals [61] .…”

Lactulose and Combination Therapy of Hepatic Encephalopathy: The Role of the Intestinal Microflora

“…Vegetable protein diets were in troduced originally with the idea that they might be useful in the treatment of hepatic encephalopathy because of variations in their amino acid composition [9]. Except for one negative study [42], vegetable protein diets have been shown to improve hepatic encepha lopathy when compared to equinitrogenous meat protein diets [9,[43][44][45], In addition to Bacterial Metabolism of Lactulose Dig Dis 1996; 14<suppl l): [53][54][55][56][57][58][59][60][61][62][63]an altered amino acid content, vegetable pro tein diets also contain from 4-to 5-fold more fiber than standard animal protein diets. The soluble metabolizable fiber component of these diets that is metabolized by the colonic microflora could increase their growth and nitrogen incorporation [26].…”