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The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus.
Hepatology 2013; 58(1):325-36Hep

Abstract

Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly.

CONCLUSION

Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE.

Authors+Show Affiliations

Department of Medicine University Hospital of Padua Padova Italy. piero.amodio@unipd.itNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Consensus Development Conference
Journal Article

Language

eng

PubMed ID

23471642

Citation

Amodio, Piero, et al. "The Nutritional Management of Hepatic Encephalopathy in Patients With Cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus." Hepatology (Baltimore, Md.), vol. 58, no. 1, 2013, pp. 325-36.
Amodio P, Bemeur C, Butterworth R, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1):325-36.
Amodio, P., Bemeur, C., Butterworth, R., Cordoba, J., Kato, A., Montagnese, S., ... Morgan, M. Y. (2013). The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology (Baltimore, Md.), 58(1), pp. 325-36. doi:10.1002/hep.26370.
Amodio P, et al. The Nutritional Management of Hepatic Encephalopathy in Patients With Cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1):325-36. PubMed PMID: 23471642.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. AU - Amodio,Piero, AU - Bemeur,Chantal, AU - Butterworth,Roger, AU - Cordoba,Juan, AU - Kato,Akinobu, AU - Montagnese,Sara, AU - Uribe,Misael, AU - Vilstrup,Hendrik, AU - Morgan,Marsha Y, Y1 - 2013/05/31/ PY - 2012/04/04/received PY - 2013/02/25/accepted PY - 2013/3/9/entrez PY - 2013/3/9/pubmed PY - 2013/8/31/medline SP - 325 EP - 36 JF - Hepatology (Baltimore, Md.) JO - Hepatology VL - 58 IS - 1 N2 - UNLABELLED: Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly. CONCLUSION: Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE. SN - 1527-3350 UR - https://www.unboundmedicine.com/medline/citation/23471642/The_nutritional_management_of_hepatic_encephalopathy_in_patients_with_cirrhosis:_International_Society_for_Hepatic_Encephalopathy_and_Nitrogen_Metabolism_Consensus_ L2 - https://doi.org/10.1002/hep.26370 DB - PRIME DP - Unbound Medicine ER -