Page 218 - Read Online

Table 4: Nutrition recommendations for a liver transplant Protein intake increased from 1.0 g/kg per day to 1.8 g/kg
candidate [58-63] per day. With increasing protein intake, 84% of the increase
Nutrient General recommendations in intake was retained. The rate of protein retention was not
Calories Energy needs vary with each individual; saturated at the intakes obtained in this study.
30-35 kcal/kg dry weight for maintenance;
35-40 kcal/kg dry weight for malnourished Protein requirement and protein utilization were investigated
patients; further by measuring protein synthesis and degradation. In
25-35 kcal/kg dry weight for hepatic 2 separate studies, patients with cirrhosis of the liver were
encephalopathy; refed on a balanced diet for an average of 2-4 weeks. Protein
150-175% of predicted basal energy expenditure and energy intakes were doubled in both studies. Refeeding
(calculated on dry weight) caused a statistically significant increase of about 30% in
Proteins 0.8-1.0 g/kg dry weight in compensated liver protein synthesis in both studies while protein degradation
disease; was only slightly affected. The increase in protein synthesis
1.5-2.0 g/kg dry weight in decompensated liver was associated with significant increases in plasma
disease; concentrations of total amino acids while insulin, growth
0.6-1.0 g/kg dry weight for hepatic hormone, IGF-1 and IGF-3 were not changed significantly.
encephalopathy, BCAA-enriched formulas The results indicate that the efficient protein utilization is
Fats 25-40% of calories, moderate amounts of medium due to increased protein synthesis, rather than decreased
chain triglycerides oil when steatorrhea present protein degradation. [5]
Carbohydrates Restrict simple carbohydrate if glucose
intolerance is present Value of branched-chain amino acids
Sodium 2-4 g/day depending upon level of fluid retention Branched-chain amino acids (BCAAs) (leucine, isoleucine,
Fluid 1,000-1,500 mL/day if fluid retention or valine) are essential amino acids. In cirrhosis, there is a likely
hyponatremia is present reduced total body pool of BCAAs due to reduced lean muscle
Vitamins Fat malabsorption leads to malabsorption of mass and defective use secondary to hyperinsulinemia. [39]
fat-soluble vitamins;
vitamin A: liver unable to synthesize BCAAs compete with the serotonin precursor tryptophan for
retinol-binding protein; the same amino acid transporter in the blood-brain barrier,
vitamin D: decreased biliary excretion of and the imbalance between the 2 in cirrhosis influences brain
1,23-dihydroxycholecalciferol; ammonia levels directly or indirectly. So supplementation
[40]
vitamin E: cholestatic liver disease affect vitamin with BCAAs may reduce brain uptake of tryptophan
E because it is carried by lipoproteins; and improve encephalopathy. [41,42] Furthermore, BCAA
B vitamins: excess losses due to alcohol abuse supplementation by both enteral and parenteral routes of
Minerals Mineral bioavailability, tissue distribution, and feeding has shown improved in cerebral perfusion by which
toxicity can be affected by decreased liver encephalopathy may get improved but still basic mechanism
production of their protein carriers;
manganese and copper excretion in bile affected is unclear. A large multicenter study showed that oral
BCAAs given for 1 year improved the Child score, reduced
by an interruption in enterohepatic circulation;
Serum potassium, magnesium, and phosphorus hospital admissions, and prolonged/improved event-free
survival. However, there have been no controlled studies
[43]
levels may decrease as a result of diuretic and no mention of the timing of BCAA supplementation in
administration, refeeding syndrome, cirrhotic patients. At 3 months, a significant increase in
[44]
malabsorption, or alcoholism; serum albumin level was observed in patients who were
800-1,200 mg calcium/day
administered with nocturnal BCAAs but not daytime BCAAs.
growth factor (IGF)-1. [19] It is hypothized that BCAAs when consumed in daytime are
utilized as calories, whereas nocturnal BCAAs are utilized
[39]
According to Morgan et al. (2006) whole protein formula for protein synthesis. European Society for Parenteral and
[37]
[45]
providing 35-40 kcal/kg per day energy and 1.2-1.5 g/kg per Enteral Nutrition (ESPEN) guidelines [Table 3] recommends
day protein is recommended for enteral feeding. Standard use of enteral feed enriched with BCAAs for patients who
preparation contains approximately 100 kcal, 4 g protein, develop encephalopathy. The use of solutions rich in BCAA
and low in aromatic acids and tryptophan in encephalopathy
and 3.5 mmol of sodium and potassium per 100 mL. has been proposed. However, a Cochrane analysis based on
[46]
Concentrated high energy (1.5 kcal/mL) and protein formulas 11 trials found no convincing evidence regarding benefit
may be preferable in patients with hyponatremia and ascites from BCAA. The use of BCAAs remains controversial, and
to regulate fluid balance. This may also improve treatment they are not widely available in many centres due to their
adherence because less volume needs to be consumed. expense and unpalatability. [47]

A study by Nielsen et al. (1995) showed protein balance in a According to ESPEN Guidelines, for a positive effect on
[38]
subgroup of patients did not change protein balance values. liver function and clinical outcome, non-protein energy
Hepatoma Research | Volume 2 | August 5, 2016 209