Long-term oral refeeding of patients with cirrhosis of the liver

Abstract

A previous study has shown that malnourished, clinically stable patients with liver cirrhosis are in protein and energy balance at their spontaneous dietary intake and that an improvement in nutritional status cannot be anticipated at this intake (Nielsen et al. 1993). In the present study we examined to what extent oral intake could be increased by nutritional support, and to what extent dietary protein would be retained with increased intake. The techniques used for balance studies were also validated since this information is not available for patients with liver cirrhosis. Fifteen malnourished patients with alcoholic liver cirrhosis were given increasing amounts of a balanced ordinary diet for 38 (SE 3) d. Intakes of protein and energy were recorded by weighing servings and leftovers on food trays. Protein intake was calculated from food tables. Total N disposal was calculated after measurement of urinary N excretion, and protein balance was calculated from the N balance. A validation study of protein balance in a subgroup of patients (analysis of N in food by the duplicate portion technique, correction for incomplete recovery of urine by measurement of urinary para-aminobenzoic acid (PABA) after administration of PABA tablets, and measurement of faecal N) did not change protein balance values. Protein intake increased from 1.0 (SE 01) g/kg per d to 1.8 (SE 0.1) g/kg per d. With increasing protein intake, 84 (SE 8) % of the increase in intake was retained. The rate of protein retention was not saturated at the intakes obtained in this study. Protein intolerance was only encountered in one patient. Available evidence indicates that the requirement for achieving N balance is increased in these patients but protein retention is highly efficient with increased intake. Protein retention is dependent on energy balance. Energy intake was calculated from food tables and total energy expenditure was calculated by the factorial method. A validation study was performed in a subgroup of patients. The energy contents of food sampled by the duplicate portion technique, and of urine and faeces were measured by bomb calorimetry. Resting energy expenditure (REE) was measured by indirect calorimetry before and at the end of the study, and 0, uptake during bicycle exercise was measured before and at the end of the study. The measured intake of metabolizable energy was on average 13% lower than the value given in food tables. Calculated energy expenditure was not changed by the validation study. Mean energy intake was 163 (SE 10) kJ/kg per d and mean energy expenditure was 134 (SE 5 ) kJ/kg per d (P = 0-007), indicating that the protein retention described occurred at a positive energy balance. It is concluded that a substantial retention of dietary protein can be obtained by oral nutrition support over a prolonged period of time in patients with liver cirrhosis. Requirements of protein for maintenance and repletion in these patients are discussed.

Resting energy expenditure should be measured in patients with cirrhosis, not predicted

“…Detailed studies have been undertaken on protein and nitrogen balance in these patients and consistent increases in their requirements clearly demonstrated. [12][13][14][15] However, there is no consensus in the data on energy expenditure, and thus energy requirements, in this patient population. [16][17][18][19][20][21][22] Plauth et al 23 recommended that energy requirements should be determined in patients with cirrhosis by measurement of their resting energy expenditure (REE) using indirect calorimetry.…”

Protein Recommendations for Older Adults with Cirrhosis: A Review

“…Protein in older cirrhotic adults of HE [37][38][39][40] . Similar studies continued in the 1990's, showing that higher amounts of protein intake do not lead to worsening of hepatic encephalopathy [41,42,45] . In 2004 and 2005, two more studies were done to completely remove any doubt as to whether or not dietary protein is harmful in HE.…”

“…Patients with a positive nitrogen balance, as a result of consuming 60-80 g of protein, saw their physical condition improve [40] . At protein intakes of 1-1.8 g/ kg/day, improved liver function has been noted [42] and at protein intakes of 1.5 g/kg, subjects improved more rapidly compared to a control group that consumed only 0.7 g/kg/d [24] . Gheorghe et al [44] has also demonstrated that at intakes of 1.2 g/kg/day, 79.7% of all patients showed improvement in mental status and decreases in blood ammonia level, regardless of tolerance to diet.…”

“…Since the 1970's, multiple studies have been done that have proven that protein restriction is not beneficial in HE; a summary of these studies can be found in table 1 [24,[36][37][38][39][40][41][42][43][44][45] . As far back as 1977,…”

Drug therapies in liver disease

“…49 Precipitants of HE include constipation, infection, gastrointestinal bleeding, sedative use and electrolyte disturbance, and these factors should be actively looked for and treated aggressively. Low protein diets were once advocated in the treatment and prevention of HE, but it is now recognised that high calorie and protein diets are well tolerated in patients with cirrhosis 50 and should be encouraged to counteract the pathological cachexia associated with advanced disease.…”