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Table 5: Major studies recommending use of nutrition supplementation
Study Recommendations Outcomes
[32]
Bories and Campillo (1994) 40 kcal/kg per day Protein and energy intakes were significantly higher;
improved nutritional satus;
improved biochemical parameters
Hirsch et al. (1993) 1,000 kcal and 35 g of nitrogen/day for Need for hospitalization was significantly lower in the
[81]
1 year supplemented;
reduction of infectious complications;
a lower mortality in the therapeutic group
[82]
Mendenhall et al. (1993) > 2,500 kcal/day 51% mortality in severe malnourished patients with
inadequate caloric intake;
19% mortality in patients who received adequate oral
nutrition
[83]
Le Cornu et al. (2000) Nutritional supplementation to Did not increase overall dietary energy or protein intake
pre-transplant candidates and did not significantly improve post- transplant
outcome; regular dietary counselling is as effective in
increasing energy intake
Kawaguchi et al. (2008) 200-kcal nutritional supplement Stress scores for physical and mental symptoms were
[84]
significantly lower compared to those in the fasting
group

was given in amounts of 35-40 kcal/kg per day plus protein serum levels. Hypovitaminosis A has been linked to night
[50]
up to 1.6 g/kg per day. In patients with encephalopathy, blindness, impairment in immune function, and also to an
transient protein restriction can be instituted, but after increased risk of hepatic fibrosis [Table 4]. If malabsorption
a few days adequate nutrition should be reinstituted. is suspected as a prime contributor to depletion, doses
Patients in coma (encephalopathy grade III-IV) can safely of 25,000-50,000 IU 3 times per week may be needed for
be given total parenteral nutrition (TPN) regimens providing repletion. Vitamin A supplementation improves the sense
25-30 kcal/kg per day from non protein energy plus 1.0 g/kg of taste and thereby may also improve dietary intake of the
per day using BCAA-enriched solutions. Fasting periods patients. Inadequate intake of calcium and vitamin D and
[14]
should not exceed 6 h due to the limited glycogen stores losses from malabsorption and renal excretion are related
in malnourished cirrhotic patients. Generally, the oral or to lower serum levels of albumin and magnesium. If the
[49]
enteral routes are preferred. Parenteral nutrition should individual is unable to increase dietary intake to a consistent,
only be used when enteral feeding is not possible or adequate level of 1,000-1,500 mg/day, supplementation
impractable [Table 3]. [45] should be initiated, especially in those with suspected low
bone mineral density. Osteoporosis has been confirmed in
Micronutrients requirements 17-23% of patients with liver disease. The role of vitamin D
Micronutrient deficiency has been observed in 10-50% of and calcium on bone mass in the setting of liver disease is
patients with cirrhosis. Multivitamin supplements may be unclear. Serum levels should be monitored in 3 months to
[51]
considered in these patients. [48] assess tolerance and success of repletion. Low serum levels of
vitamin D are thought to be the result of poor dietary intake,
Vitamins malabsorption from cholestasis, pancreatic insufficiency, and
Various vitamins deficiency occurs in LT recipients like folate decreased sunlight exposure. Supplementation usually
[52]
deficiency is due to a combination of decreased intake, begins at 400 IU per day, with some patients requiring up to
decreased absorption, as well as losses from renal excretion 800 IU per day of vitamin D or 12,000-50,000 IU per day of
and poor hepatic storage. Supplementation of folate and ergocalciferol, with serum levels reassessed in 2-3 months.
[53]
B12 is crucial in alcoholic hepatitis to protect uninjured Serum vitamin E levels are typically decreased in alcoholic
hepatocytes and stimulate the repair/replacement of patients, pancreatitis or fat malabsorption [Table 4]. A dose of
damaged cells [Table 4]. The common recommendation 400 IU per day either as standard vitamin E or as α-tocopherol,
for folate supplementation is 1 mg/day orally. Vitamin B1 if malabsorption is suspected, should provide for adequate
[48]
deficiency is linked to primary tissue damage such as alcoholic supplementation in most individuals. [49]
polyneuropathy and also Wernicke’s encephalopathy. Usual
supplementation is 100 mg/day orally or subcutaneously Minerals
initially for 2 weeks or until repleted, the amount in a During the pre-LT phase patients suffer from various mineral
standard multivitamin should be sufficient. Deficiency of deficiencies because of metabolic changes due to liver
[48]
vitamin B6 (pyridoxine) is due to decreased intake or altered impairment. Zinc deficiency is very common in cirrhotics.
[54]
metabolism and storage. Standard supplementation is 50- Zinc supplementation may also be used for those patients
[49]
100 mg/day orally, or more in severely depleted individuals. with hepatic encephalopathy, with refractory response
Liver stores are often depleted even in the setting of normal to vitamin A supplementation for night blindness, and
210 Hepatoma Research | Volume 2 | August 5, 2016