VA Cooperative Study on Alcoholic Hepatitis III: Changes in Protein‐Calorie Malnutrition Associated with 30 Days of Hospitalization with and without Enteral Nutritional Therapy

Abstract

Patients with moderate to severe alcoholic hepatitis and features of protein-calorie malnutrition were studied with respect to changes in their nutritional status during 30 days of hospitalization. Thirty-four patients served as controls, were given a 2500 kcal hospital diet and allowed to eat ad libitum. Twenty-three patients were given, in addition to the hospital diet, a nutrition supplement high in calories, protein, and branched-chain amino acids (Hepatic Aid). Because of anorexia, the controls consumed lesser amounts of both calories and protein while those given the nutritional therapy exceeded their estimated energy requirements (116.1%) and consumed a mean of 98.3 g of protein per day. This was well tolerated despite the fact that portal systemic encephalopathy was present in 72% of the patients. Mortality associated with the liver disease was comparable in both groups, 16.7% in the treated vs 20.6% in the controls. In those patients that survived the 30 days of hospitalization, clinical and biochemical tests of liver injury improved in both groups. With respect to their nutritional status, those given nutritional therapy showed significant improvement in six of the nine parameters (67%) used to assess nutrition. In the controls significant improvement was observed in only two nutritional parameters (22%) while three parameters (33%) deteriorated further. These three were all associated with calorie deprivation (marasmus). This study suggests that patients with acute alcoholic hepatitis require additional nutritional therapy to maintain and improve their nutrition parameters, especially those related to marasmus; and that Hepatic Aid is well tolerated for this purpose.

Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: A multicenter randomized trial

“…This finding is in agreement with that observed in a randomized controlled trial of 30-day enteral feeding versus conventional diet in AH, in which all deaths in the enteral feeding group were concentrated in the first week of therapy. 11 Other characteristics of the enteral diet used in the present trial (Table 1) might also contribute to its therapeutic effect. It was a low-fat diet (about 15% of energy as fat), and medium-chain triglycerides and oleic acid accounted for most of its lipid content.…”

Nutrition and liver diseases

“…Protein-energy malnutrition has been shown to worsen the prognosis of alcoholic hepatitis [32]. One large controlled trial has shown benefits of short-term enteral feeding in patients with alcoholic hepatitis, including improved liver function tests and shorter hospital stay [33]; however, no decrease in mortality has been reported. During the anorectic phase of alcoholic hepatitis, enteral nutrition should be started to provide sufficient protein and energy to support these catabolic patients.…”

Alcoholic steatohepatitis

“…Short-term mortality and one-year probability of survival between groups were similar, but a significantly better outcome during the one-year follow-up was recorded for patients treated with TEN compared to those treated with prednisolone alone (2 vs. 10 deaths, respectively; p ¼ 0.04), mostly due to infections. Two other trials showed a treatment benefit on surrogate parameters of nutritional status such as serum albumin, retinol-binding protein and nitrogen balance [58,59], but not on survival.…”

“…Though not being an independent prognostic factor for survival, malnutrition correlates significantly with liver dysfunction in ASH [56]. So far, five trials have studied the efficacy of oral or enteral nutritional support in patients with ASH [55,[57][58][59][60][61].…”