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Table 6: Guidelines for pre-transplant nutrition support [31,37,63,89,90]
ESPEN Guidelines Recommendations for nutrition
For organ transplantation 2006 Under nutrition majorly influence outcome after LT;
use additional oral nutrition supplementation or even tube feeding;
EN improves nutritional status and liver function, reduces the rate of
complications, cost and prolongs survival;
assess nutritional status regularly
For enteral nutrition for liver disease 2006 Use high-energy formulae in patients with ascites;
increased protein requirements;
use BCAA-enriched formulae (hepatic encephalopathy);
EN and probiotic formula reduces the incidence of infections;
hepatic encephalopathy must be treated with lactulose or rifaximin;
normal protein diets can be given safely to patients with hepatic
encephalopathy;
recommended protein supplementation is based on “dry” body
weight;
recommended to insert fine bore nasogastric tubes in patients with
esophageal varices
For parenteral nutrition in hepatology 2006 PN is indicated in unprotected airways, encephalopathy and
moderately or severely malnourished cirrhotics;
cirrhotics who have to abstain from food temporarily for > 12 h
should be given i.v. glucose at 2-3 g/kg per day. When this fasting
period lasts longer than 72 h TPN is required;
the i.v. provision of all macro- and micronutrients must be ensured
from the beginning of PN;
carbohydrate should be given as glucose to cover 50-60% of
non-protein energy requirements;
in case of hyperglycaemia glucose infusion should be reduced to 2-3
g/kg per day and i.v. insulin infusion should be used;
lipid should be provided using emulsions, should cover 40-50% of
non-protein energy requirements
ESPEN: European Society for Parenteral and Enteral Nutrition; BCAA: branched-chain amino acids; LT: liver transplantation; EN: enteral
nutrition; TPN: total parenteral nutrition

for potential improvement in immune function and taste hypertension, is a common complication of ESLD and
perception. Supplementation in the form of 220 mg zinc associated with a poor prognosis. The squeal of impaired
[64]
[49]
sulphate is given in 1-3 divided doses per day. Zinc and renal perfusion and fluid volume expansion can precipitate
selenium deficiency has been observed in both alcoholic hyponatremia as well. Spontaneous bacterial peritonitis
[65]
and non-alcoholic liver disease and may be associated with may develop which is associated with increased mortality.
[66]
neurological symptoms. Depleted serum iron levels, Nutrition issues may occur in cirrhotics with ascites due to
[55]
[49]
blood losses can cause deficiency in LT patients. Hepatic decreased intake from early satiety, increase in REE before
iron overload is common and often secondary to increased paracentesis. Also, imposing dietary restrictions of sodium
intestinal iron absorption and transfusions, and may imitate and fluid reduces the palatability of food. [22]
hemochromatosis as well as increase the risk of developing
progression of liver disease. Patients undergoing LT are The American Association for the Study of Liver Disease
[56]
prone to hypomagnesemia, with potential deleterious practice guidelines (2004), recommend sodium restricted
effects. A study evaluated the efficacy and safety of routine diet and diuretic therapy as the mainstay of treatment for
intraoperative magnesium supplementation to prevent ascites, with their effectiveness demonstrated in about 90% of
hypomagnesemia. The results showed lower prevalence patients. A dietary sodium restriction of 2 g/day appropriately
[57]
of postoperative hypomagnesemia in patients administered balances the need for adequate nutrition and fluid status.
magnesium supplementation of 3 g [Table 4] [58-63] but may not The reduction in ascitic fluid through careful diuresis can
affect the occurrence of arrhythmias. relieve early satiety. A 24-h urinary sodium excretion with a
goal of ≥ 78 mEq urinary sodium per day can be measured
CHALLENGE IN PRE-TRANSPLANT NUTRITION to follow compliance to a sodium-restricted diet. A fluid
SUPPORT restriction is appropriate in cirrhotic patients with dilutional
hyponatremia or serum sodium levels < 125 mg/dL [Table 4].
Ascites, defined as the accumulation of fluid within Small, frequent feedings and an adequate intake of protein,
the peritoneal cavity as a direct consequence of portal in addition to the sodium restriction, are important dietary
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