Author: Olivia MossUnit: University of California, David Sri Lanka Health CenterAs an important organ of metabolism and synthesis in the human body, the damage of the liver and the decline of its function will lead to the three nutrients of carbohydrates, fat and protein, and Abnormal metabolism of various substances such as vitamins and trace elements. For the above reasons, patients with liver cirrhosis are generally at risk of malnutrition, and the incidence of malnutrition in patients with decompensated cirrhosis can be as high as 50% to 90%. Prevention and management of malnutrition are critical for improving clinical outcomes in patients with cirrhosis. To prevent and treat malnutrition in patients with cirrhosis, clinicians need to prioritize patient nutritional care. Given the complexity of nutritional care, registered dietitians should also be involved in the care of these patients to complete detailed nutritional assessments and interventions. Changes in the patient’s own health knowledge base, socioeconomic status, social support, and mental status should be taken into account when conducting nutritional assessments and providing dietary education for patients. Therefore, in order to achieve individualized nutritional management, different considerations need to be prioritized (Figure 1).
Second Priority: Adequate Protein Intake
After improving the patient’s overall caloric intake, a second factor of nutritional intake can be considered: protein intake. Ensuring that patients are meeting their protein needs is key to maintaining lean body mass. The recommended protein intake is 1.0-1.5 g/kg (Table 1). In order to prevent hepatic encephalopathy, the maximum intake of protein was also limited, but recent studies have shown that low-protein diet and the resulting or aggravated sarcopenia are As an independent risk factor for hepatic encephalopathy in patients with cirrhosis, including those after transjugular intrahepatic portosystemic shunt (TIPS), protein intake should not be restricted in the latest EASL and ESPEN guidelines. The recommendations of the guidelines of the Chinese Society of Hepatology are: (1) for patients with mild hepatic encephalopathy, there is no need to reduce or even prohibit protein intake; (2) for patients with severe hepatic encephalopathy, the Comprehensive judgment of function and hepatic encephalopathy, reduce or temporarily limit protein intake as appropriate, and gradually increase protein intake to the target amount as soon as possible according to the patient’s tolerance; (3) It is recommended that patients with hepatic encephalopathy consume a total of daily protein intake. Spread the amount over multiple meals (4-6 small meals) to improve tolerance.
Third consideration: dietary composition and timing strong>
The third focus of nutritional management in patients with cirrhosis is the ideal dietary composition and frequency of eating. Considering the impaired function of the liver to store glycogen in patients with cirrhosis, a mixed intake of carbohydrates and protein ensures that there is enough protein to maintain and rebuild muscle tissue. Eating regularly and frequently during waking hours can help patients meet nutritional needs and reduce the time the patient’s body is in a fasting state. It is recommended to eat small and frequent meals with the same calorie intake. You can add 1 meal each to brunch, lunch and dinner, and before going to bed.
Fourth consideration: source of protein
On the premise that the patient’s nutritional intake meets the above recommendations, discussing the source of protein can further optimize nutritional care. Patients can get a higher percentage of protein from dairy products. The tolerance of plant protein is better than that of animal protein, and at the same time, it can be rich in dietary fiber, which can prevent or alleviate hepatic encephalopathy by regulating intestinal microecology and laxative. In addition, whey protein and plant foods (such as tofu, soybeans, etc.) are rich in branched-chain amino acids (BCAAs). Patients with liver cirrhosis lead to amino acid imbalance due to changes in amino acid metabolism, mainly manifested in decreased levels of BCAA, increased levels of aromatic amino acids (AAA), and lack of synthesizable amino acids in skeletal muscle. BCAAs of proteins. At the same time, this amino acid imbalance may lead to hepatic encephalopathy or other neurological complications and is associated with poor prognosis in cirrhosis. It should be noted that physicians should not discourage patients from consuming animal-based proteins—if patients do not consume these foods in their daily lives,It is difficult to meet the total protein requirement.
Conclusion
In general, aggressive early nutritional care as part of a patient’s overall medical management is critical to improving patient outcomes. Given the risk of malnutrition in patients with cirrhosis, nutritional assessment and education should be performed on a regular basis.
Yimaitong compiled from:Olivia Moss. Nutrition Priorities Liver Cirrhosis. Clin Liver Dis. 06 November 2019. https://doi.org/10.1002/cld.831< /span>