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measures for the patient. Contraindication of these measures to prevent and treat malnutrition in liver diseases. The
lead to large-volume paracentesis (intravenous albumin) or data suggested that by providing medical nutrition therapy,
transjugular intrahepatic portosystemic shunt placement nutrition status may be improved and complications of
may be necessary. [66,67] cirrhosis may be decreased (less hospital admissions,
decreased hepatic encephalopathic symptoms, infections,
OTHER NUTRITIONAL FACTORS gastrointestinal bleeding, ascites), although the true
impact on survival is still unclear. [79,80] Various studies
Probiotics recommending use of nutrition supplementation for LT
Current evidences have shown the advantages of probiotic patients are depicted in Table 5. [32,81-84]
use in preventing post LT infection, as well as improving
the hyperdynamic circulatory state of cirrhosis, hepatic Enteral and parenteral nutrition
encephalopathy, and Child-Pugh class. [68,69] Its evaluated Studies show an increased dietary intake by oral nutrition,
that neutrophil phagocytic capacity improved in cirrhotic improves in liver function and lower hospital mortality than
and hepatic encephalopathy patients after probiotics enetral and parenteral. [31,85] Most of the well-nourished patients
supplementation which prevents infections by altering admitted with variceal bleeding and other complications
gut microbiota, preventing bacterial translocation and failed to show benefit in nutritional status or disease-related
decreasing endotoxin levels which leads to the restoration morbidity and mortality. In hospitalized patients with poor
of the immune system. [70-72] The effect of probiotic mix (8 dietary intake, enteral nutrition (EN) should be initiated in
strains of Lactobacillus, Bifidobacterium and Streptococcus) about 24-48 h of admission. Hasse et al. demonstrated
[87]
[86]
for 2 months was assessed on portal hypertension, which early enteral feeding benefits like improved nitrogen balance
showed no reduction on hepatic venous pressure gradient or and fewer viral infections after LT.
bacterial translocation in patients with compensated or early
decompensated cirrhosis. But, Lata et al. (2007) observed PN should be used as a second line approach in those who
[73]
[74]
a trend towards decreased endotoxemia and an improvement cannot be fed adequately by the oral or enteral route,
in Child-Pugh scores (results not statistically significant) with patients with unprotected airways and advanced hepatic
use of the Escherichia coli Nissle [(2.5-25) × 10 bacteria in 1 encephalopathy, after visceral surgery in cirrhotics, a lower
9
capsula, for 42 days) in 39 cirrhotic patients. complication rate was observed when postoperative PN
was given instead of just fluid and electrolytes; usually
Immunonutrition standard amino acid formula is recommended. [16,88] In a direct
The impact of nutritional interventions with immune comparison between PN and early EN, both strategies proved
modulating enteral diets in patients’ pre- and post-LT showed to be equally effective with regard to the maintenance of
possibility of improved preoperative nutritional status of nutritional state. [89]
ESLD patients, thus reducing infectious complications after
transplantation. Qiu et al. (2009) investigated the effect DISCUSSION
[75]
[76]
of TPN supplemented with alanyl-glutamine dipeptide in
cirrhotic patients undergoing LT. Within 9 days, the group Different mechanisms are known for the nutritional
supplemented had a significant increase in the prognostic derangement in ESLD patients. These include malabsorption,
nutrition index and prealbumin levels compared with day poor dietary intake, low protein synthesis, higher intestinal
2 levels. It was observed better improvement in aspartate protein losses, disturbances in substrate utilization, and
[8]
amino transferase and reduced hepatic cell injury compared hypermetabolism. Poor dietary intake is one of the major
with the traditional TPN group and a significant decrease in contributors to ESLD malnutrition. Also, various metabolic
postoperative hospital stay. disturbances like increased REE, insulin resistance, and low
respiratory quotient which indicates decreased glucose and
Nocturnal meals increased lipid oxidation which can contribute to nutritional
[9]
A study by Plank et al. (2008) showed the effects of night- depletion in liver disease. Early nutrition therapy intervention
[77]
time and day time nutritional supplementation over a can improve response to treatment; alleviate symptoms, and
[90]
12-month period on body protein stores in cirrhotic patients. quantity of life of ESLD patients. In this review, medical
Significant accretion of total body protein equivalent to nutrition therapy goals for pre-LT patients are discussed.
about 2 kg of lean tissue was seen in patients having night- Various guidelines have been established for pre-LT nutrition
time supplementation. In the daytime group, no significant care. ESPEN guidelines for chronic liver disease showed
accretion was seen. Confirming this, a classical study showed increased calorie and protein requirement in malnourished
nocturnal supplementation in cirrhotic patients would liver disease patients (30-35 kcal/kg per day and 1.5 g/kg
[45]
improve and prevent catabolic states and under nutrition. [78] per day). Also malabsorption of other nutrients increases
requirements of other vitamins and minerals like Ca, Mg,
ROUTES OF FEEDING vitamin A, B, D, E and complications like ascites recommends
[64]
use of low sodium diet which can lead to hyponatermia.
Nutrition supplementation ESPEN guidelines for organ transplantation recommends
Oral intake, including supplements, is the first line therapy enteral nutrition or oral nutritional supplementation which
212 Hepatoma Research | Volume 2 | August 5, 2016