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Nutritional Supplementation for Patients with Decompensated Cirrhosis

  • Nutrition in Patients with Chronic Liver Disease (A Montano-Loza, Section Editor)
  • Published:
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Abstract

Purpose of Review

Malnutrition is common in patients with decompensated cirrhosis and portal hypertension and is associated with impaired health-related quality of life and reduced survival. This review aims to explore the outcomes of specific nutritional interventions in the management of malnourished patients with decompensated cirrhosis.

Recent Findings

Nutritional assessment and intervention is an important adjunct in the management of decompensated cirrhosis. Nutrition support in patients with decompensated cirrhosis can preserve muscle mass and alleviate the manifestations of decompensation including ascites, hepatic encephalopathy and muscle cramps.

Summary

Addressing nutritional deficiencies in cirrhosis is integral to the care of these patients. Current nutritional management strategies and targeted supplementation in decompensated cirrhosis can improve symptoms of decompensation and quality of life as well as improve patient survival.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Van den Burghe G. The role of the liver in metabolic homeostasis: implications for inborn errors of metabolism. J lnherit Metab Dis. 1991;14:407–20. https://doi.org/10.1007/BF01797914.

    Article  Google Scholar 

  2. Saunders J, Brian A, Wright M, Stroud M. Malnutrition and nutrition support in patients with liver disease. Frontline Gastroenterol. 2010;1:105–11. https://doi.org/10.1136/fg.2009.000414.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Lautz HU, Selberg O, Körber J, Bürger M, Müller MJ. Protein-calorie malnutrition in liver cirrhosis. Clin Investig. 1992;70:478–86. https://doi.org/10.1007/BF00210228.

    Article  CAS  PubMed  Google Scholar 

  4. •• Merli M. Nutrition in cirrhosis: dos and don’ts. J Hepatol. 2020;S0168-8278:30474–8. https://doi.org/10.1016/j.jhep.2020.07.019These references highlight current clinical guidelines for the management of patients with liver disease and the significant issue of sarcopenic obesity in liver disease.

    Article  Google Scholar 

  5. Chang WK, Chao YC, Tang HS, Lang HF, Hsu CT. Effects of extra-carbohydrate supplementation in the late evening on energy expenditure and substrate oxidation in patients with liver cirrhosis. JPEN J Parenter Enteral Nutr. 1997;21:96–9. https://doi.org/10.1177/014860719702100296.

    Article  CAS  PubMed  Google Scholar 

  6. Anand AC. Nutrition and Muscle in Cirrhosis. J Clin Exp Hepatol. 2017;7:340–57. https://doi.org/10.1016/j.jceh.2017.11.001.

    Article  PubMed  PubMed Central  Google Scholar 

  7. König M, Bulik S, Holzhütter H-G. Quantifying the contribution of the liver to glucose homeostasis: a detailed kinetic model of human hepatic glucose metabolism. PLoS Comput Biol. 2012;8:e1002577. https://doi.org/10.1371/journal.pcbi.1002577.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Adeva-Andany MM, Perez-Felpete N, Fernández-Fernández C, Donapetry-García C, Pazos-García C. Liver glucose metabolism in humans. Biosci Rep. 2016;36:e00416. https://doi.org/10.1042/BSR20160385.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Krähenbühl L, Lang C, Lüdes S, Seiler C. Reduced hepatic glycogen stores in patients with liver cirrhosis. Liver Int. 2003;23:101–9. https://doi.org/10.1034/j.1600-0676.2003.00805.x.

    Article  PubMed  Google Scholar 

  10. Plauth M, Merli M, Kondrup J, Weimann A, Ferenci P, Müller MJ. ESPEN guidelines for nutrition in liver disease and transplantation. Clin Nutr. 1997;16:43–55. https://doi.org/10.1016/s0261-5614(97)80022-2.

    Article  CAS  PubMed  Google Scholar 

  11. Alberino F, Gattta A, Amodio P, et al. Nutrition and survival in patients with liver cirrhosis. Nutrition. 2001;17:445–50. https://doi.org/10.1016/s0899-9007(01)00521-4.

    Article  CAS  PubMed  Google Scholar 

  12. •• Plauth M, Bernal W, Dasarathy S, Merli M, Plank L, Schütz T, et al. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr. 2019;38:220–75. https://doi.org/10.1016/j.clnu.2018.12.022These references highlight current clinical guidelines for the management of patients with liver disease and the significant issue of sarcopenic obesity in liver disease.

    Article  Google Scholar 

  13. Montano-Loza AJ, Meza-Junco J, Prado CMM, Lieffers JR, Baracos VE, Bain VG, et al. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2012;10:166–73. https://doi.org/10.1016/j.cgh.2011.08.028.

    Article  PubMed  Google Scholar 

  14. Bunchorntavakul C, Reddy KJ. Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis. Aliment Pharmacol Ther. 2019;51:64–77. https://doi.org/10.1111/apt.15571.

    Article  PubMed  Google Scholar 

  15. Dasarathy S. Etiology and Management of muscle wasting in chronic liver disease. Curr Opin Gastroenterol. 2016;32:59–165. https://doi.org/10.1097/MOG.0000000000000261.

    Article  CAS  Google Scholar 

  16. Calmet F, Martin P, Pearlman M. Nutrition in patients with cirrhosis. Gastroenterol Hepatol (NY). 2019;15:248–54.

    Google Scholar 

  17. Hasse J, Strong S, Gorman MA, Liepa G. Subjective global assessment: Alternative nutrition-assessment technique for liver-transplant candidates. Nutrition. 1993;9:339–43.

    CAS  PubMed  Google Scholar 

  18. Morgan MY, Madden AM, Soulsby CT, Morris RW. Derivation and validation of a new global method for assessing nutritional status in patients with cirrhosis. Hepatology. 2006;44:823–35. https://doi.org/10.1002/hep.21358.

    Article  PubMed  Google Scholar 

  19. Vidot H, Kline K, Cheng R, Finegan L, Lin A, Kempler E, et al. The relationship of obesity, nutritional status and muscle wasting in patients assessed for liver transplantation. Nutrients. 2019;11:2097. https://doi.org/10.3390/nu11092097.

    Article  CAS  PubMed Central  Google Scholar 

  20. •• Eslamparast T, Montano-Loza A, Raman M, Tandon P. Sarcopenic obesity in cirrhosis – The confluence of 2 prognostic titans. Liver Int. 2018;38:1706–17. https://doi.org/10.1111/liv.13876These references highlight current clinical guidelines for the management of patients with liver disease and the significant issue of sarcopenic obesity in liver disease.

    Article  PubMed  Google Scholar 

  21. •• Merli M, Berzigotti A, Zelber-Sagi S, Dasarathy S, Montagnese S, Genton L, et al. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol. 2019;70:72–193. https://doi.org/10.1016/j.jhep.2018.06.024These references highlight current clinical guidelines for the management of patients with liver disease and the significant issue of sarcopenic obesity in liver disease.

    Article  Google Scholar 

  22. Norman K, Kirchner H, Lochs H. Malnutrition affects quality of life in gastroenterology patients. World J Gastroenterol. 2006;12:3380–5. https://doi.org/10.3748/wjg.v12.i21.3385.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Younossi Z, Henry L. Overall health-related quality of life in patients with end-stage liver disease. Clin Liver Dis. 2015;6:9–14. https://doi.org/10.1002/cld.480.

    Article  Google Scholar 

  24. Montagnese S, De Pittà C, Rui M, Corrias M, Turco M, Merkel C, et al. Sleep-wake abnormalities in patients with cirrhosis. Hepatology. 2014;59:705–12. https://doi.org/10.1002/hep.26555.

    Article  PubMed  Google Scholar 

  25. Bruyneel M, Sersté T. Sleep disturbances in patients with liver cirrhosis: prevalence, impact, and management challenges. Nat Sci Sleep. 2018;10:369–75. https://doi.org/10.2147/NSS.S186665.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Changani KK, Jalan R, Cox IJ, Ala-Korpela M, Bhakoo K, Taylor-Robinson SD, et al. Evidence for altered hepatic gluconeogenesis in patients with cirrhosis using in vivo 31-phosphorus magnetic resonance spectroscopy. Gut. 2001;49:557–64. https://doi.org/10.1136/gut.49.4.557.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Owen OE, Trapp VE, Reichard GA, Mozzoli MA, Moctezuma J, Paul P, et al. Nature and quantity of fuels consumed in patients with alcoholic cirrhosis. J Clin Investig. 1983;72:1821–32. https://doi.org/10.1172/JCI111142.

    Article  CAS  PubMed  Google Scholar 

  28. Maharshi S, Sharma BC, Sachdeva S, Srivastava S, Sharma P. Efficacy of nutritional therapy for patients with cirrhosis and minimal hepatic encephalopathy in a randomized trial. Clin Gastroenterol Hepatol. 2015;14:454–60. https://doi.org/10.1016/j.cgh.2015.09.028.

    Article  PubMed  Google Scholar 

  29. Plank LD, Gane EJ, Peng S, Muthu C, Mathur S, Gillanders L, et al. Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial. Hepatology. 2008;48:557–66. https://doi.org/10.1002/hep.22367.

    Article  PubMed  Google Scholar 

  30. Miwa Y, Shiraki M, Kato M, Tajika M, Mohri H, Murakami N, et al. Improvement of fuel metabolism by nocturnal energy supplementation in patients with liver cirrhosis. Hepatol Res. 2000;18:184–9. https://doi.org/10.1016/s1386-6346(99)00100-x.

    Article  CAS  PubMed  Google Scholar 

  31. Tsien C, McCullough AJ, Dasarathy S. Late evening snack: Exploiting a period of anabolic opportunity in cirrhosis. J Gastroenterol Hepatol. 2012;27:430–41. https://doi.org/10.1111/j.1440-1746.2011.06951.x.

    Article  CAS  PubMed  Google Scholar 

  32. Müller MJ, Lautz HU, Plogmann B, Burger M, Korber J, Schmidt FW. Energy expenditure and substrate oxidation in patients with cirrhosis: the impact of cause, clinical staging and nutritional state. Hepatology. 1992;15:782–94. https://doi.org/10.1002/hep.1840150507.

    Article  PubMed  Google Scholar 

  33. Amodio P, Bemeur C, Butterworth R, Cordoba J, Kato A, Montagnese S, et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58:325–36. https://doi.org/10.1002/hep.26370.

    Article  CAS  PubMed  Google Scholar 

  34. Moss O. Nutrition priorities: diet recommendations in liver cirrhosis. Clin Liver Dis. 2019;4:146–8. https://doi.org/10.1002/cld.831.

    Article  Google Scholar 

  35. Palmer LB, Kuftinec G, Pearlman M, Homberger Green C. Nutrition in cirrhosis. Curr Gastroenterol Rep. 2019;21:38. https://doi.org/10.1007/s11894-019-0706-5.

    Article  PubMed  Google Scholar 

  36. Volk ML. Burden of Cirrhosis on Patients and Caregivers. Hepatol Commun. 2020;4:107–1111. https://doi.org/10.1002/hep4.1526.

    Article  Google Scholar 

  37. Reuter B, Shaw J, Hanson J, Tate V, Acharya C, Bajaj JS. Nutritional assessment in inpatients with cirrhosis can be improved after training and is associated with lower readmissions. Liver Transpl. 2019;25:1790–9. https://doi.org/10.1002/lt.25602.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Tierney EP, Sage RJ, Shwayder T. Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature. Int J Dermatol. 2010;49:500–6. https://doi.org/10.1111/j.1365-4632.2010.04253.x.

    Article  PubMed  Google Scholar 

  39. • Angeli P, Bernardi M, Villanueva C, Francoz C, Mookerjee RP, Trebicka J, et al. EASL Clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2018;69:406–60. https://doi.org/10.1016/j.jhep.2010.05.004Current guidelines for the management of ascites prioritise increased protein and energy requirements over salt restriction.

    Article  Google Scholar 

  40. Haberi J, Zollner G, Fickert P, Stadlbauer V. To salt or not to salt? – That is the question in cirrhosis. Liver Int. 2018;38:1148–59. https://doi.org/10.1111/liv.13750.

    Article  Google Scholar 

  41. Bashar AA, Scopalio JS, Dickson RC, Burton DD, Bouras EP. Contribution of Ascites to Impaired Gastric Function and Nutritional Intake in Patients with Cirrhosis and Ascites. Clin Gastroenterol Hepatol. 2015;3:095–1100. https://doi.org/10.1016/s1542-3565(05)00531-8.

    Article  Google Scholar 

  42. Vidot H, Bowen D, Carey S, McCaughan GW, Allman-Farinelli M, Shackel N. Aggressive nutrition intervention reduces ascites and frequency of paracentesis in malnourished patients with cirrhosis and ascites. JGH Open. 2017;1:92–7. https://doi.org/10.1002/jgh3.12016.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen K, et al. Practice Guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases. J Hepatol. 2014;2014(61):642–59. https://doi.org/10.1002/hep.27210.

    Article  Google Scholar 

  44. Elwir S, Rahimi RS. Hepatic encephalopathy: an update on the pathophysiology and therapeutic options. J Clin Transl Hepatol. 2017;5:142151. https://doi.org/10.14218/JCTH.2016.00069.

    Article  Google Scholar 

  45. Dam G, Ott P, Aagaard NK, Vilstrup H. Branched-chain amino acids and muscle ammonia detoxification in cirrhosis. Metab Brain Dis. 2013;28:217–20. https://doi.org/10.1007/s11011-013-9377-3.

    Article  CAS  PubMed  Google Scholar 

  46. Holecek M. Branched-chain amino acids and ammonia metabolism in liver disease: therapeutic implications. Nutrition. 2013;10:575–84. https://doi.org/10.1016/j.nut.2013.01.022.

    Article  CAS  Google Scholar 

  47. Fallahzadeh MD, Rahimi RS. Hepatic encephalopathy and nutrition influences: a narrative review. NCP. 2020;35:36–48. https://doi.org/10.1002/ncp.10458.

    Article  PubMed  Google Scholar 

  48. Bajaj JS. The role of microbiota in hepatic encephalopathy. J Gut Microbes. 2014;5:397–403. https://doi.org/10.4161/gmic.28684.

    Article  Google Scholar 

  49. Merli M, Giusto M, Lucidi C, Giannelli V, Pentassuglio I, Di Gregorio V, et al. Muscle depletion increases the risk of overt and minimal hepatic encephalopathy: results of a prospective study. Metab Brain Dis. 2013;28:281–4. https://doi.org/10.1007/s11011-012-9365-z.

    Article  CAS  PubMed  Google Scholar 

  50. Vidot H, Potter A, Cheng R, Allman-Farinelli M, Shackel N. Serum 25-hydroxyvitamin D deficiency and hepatic encephalopathy in chronic liver disease. J Hepatol. 2017;9:510–8. https://doi.org/10.4254/wjh.v9.i10.510.

    Article  Google Scholar 

  51. Kornerup LS, Gluud LL, Vilstrup H, Dam G. Update on the therapeutic management of hepatic encephalopathy. Gastroenterol Rep. 2018;20(5):21. https://doi.org/10.1007/s11894-018-0627-8.

    Article  Google Scholar 

  52. Bajaj J, Lauridsen M, Tapper EB, Duarte-Rojo A, Rahimi RS, Tandon P, et al. Important unresolved questions in the management of hepatic encephalopathy: An ISHEN Consensus. Am J Gastroenterol. 2020;30:989–1002. https://doi.org/10.14309/ajg.0000000000000603.

    Article  Google Scholar 

  53. Bass N, Mullen K, Sanyal A, Poordad F, Neff G, Leevy CB, et al. Rifaximin treatment in hepatic encephalopathy. NEJM. 2010;362:1071–81. https://doi.org/10.1056/NEJMoa0907893.

    Article  CAS  PubMed  Google Scholar 

  54. Cabral CM, Burns DL. Low-protein diets for hepatic encephalopathy debunked: let them eat steak. Nutr Clin Pract. 2011;26:155–9. https://doi.org/10.1177/0884533611400086.

    Article  PubMed  Google Scholar 

  55. Kato A, Tanaka H, Kawaguchi T, Kanazawa H, Iwasa M, Sakaida I, et al. Nutritional management contributes to improvement in minimal hepatic encephalopathy and quality of life in patients with liver cirrhosis: A preliminary, prospective, open-label study. Hepatol Res. 2013;43:452–8. https://doi.org/10.1111/j.1872-034X.2012.01092.x.

    Article  CAS  PubMed  Google Scholar 

  56. Meyer F, Bannert K, Wiese M, Esau S, Sautter LF, Ehlers L, et al. Molecular mechanism contributing to malnutrition. Int J Mol Sci. 2020;21:5357. https://doi.org/10.3390/ijms21155357.

    Article  CAS  PubMed Central  Google Scholar 

  57. Shaw J, Tate V, Hanson J, Bajaj JS. What diet should i recommend my patient with hepatic encephalopathy? Curr Hepatol Rep. 2020;19:13–22. https://doi.org/10.1007/s11901-020-00510-4.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Gluud LL, Dam G, , Marchesini G, Borre M, Aagaard NK, Vilstrup H and Cochrane Hepato-Biliary Group. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev 2017:5:CD001939. Doi: https://doi.org/10.1002/14651858.CD001939.pub4.

    Article  PubMed  Google Scholar 

  59. Dalal R, McGee RG, Riordan SM, Webster AC. Probiotics for people with hepatic encephalopathy. Cochrane Database Syst Rev. 2017;2:CD008716. https://doi.org/10.1002/14651858.CD008716.pub3.

    Article  PubMed  Google Scholar 

  60. Vidot H, Cvejic E, Finegan L, Shores EA, Bowen DG, Strasser SI, et al. Supplementation with Synbiotics and/or Branched Chain Amino Acids in Hepatic Encephalopathy: A Pilot Randomised Placebo-Controlled Clinical Study. Nutrients. 2019;11:1810. https://doi.org/10.3390/nu11081810.

    Article  CAS  PubMed Central  Google Scholar 

  61. Konikoff F, Theodor E. Painful muscle cramps. A symptom of liver cirrhosis? J Clin Gastroenterol. 1986;8:669–72. https://doi.org/10.1097/00004836-198612000-00017.

    Article  CAS  PubMed  Google Scholar 

  62. Abrams GA, Concato J, Fallon MB. Muscle cramps in patients with cirrhosis. Am J Gastroenterol. 1996;91:1363–6.

    CAS  PubMed  Google Scholar 

  63. Maciocia G. The Foundations of Chinese Medicine: A Comprehensive Text. Seattle: Eastland Press, Inc.; 2009.

    Google Scholar 

  64. Garrison SR, Allan GM, Sekhon RK, Musini VM, Khan KM. Magnesium for skeletal muscle cramps. Cochrane Database Syst Rev. 2012;9:CD009402. https://doi.org/10.1002/14651858.CD009402.pub2.

    Article  Google Scholar 

  65. Vidot H, Carey S, Allman-Farinelli M, Shackel N. Systematic review: the treatment of muscle cramps in patients with cirrhosis. Aliment Pharmacol Ther. 2014;40:221–32. https://doi.org/10.1111/apt.12827.

    Article  CAS  PubMed  Google Scholar 

  66. Nakanishi H, Kurosaki M, Tsuchiya K, Nakakuki N, Takada H, Matsuda S, et al. L-carnitine Reduces Muscle Cramps in Patients with Cirrhosis. Clin Gastroenterol Hepatol. 2015;13:540–1543. https://doi.org/10.1016/j.cgh.2014.12.005.

    Article  CAS  Google Scholar 

  67. • Vidot H, Cvejic E, Carey S, Strasser SI, McCaughan GW, Allman-Farinelli M, et al. Randomised clinical trial: oral taurine supplementation versus placebo reduces muscle cramps in patients with chronic liver disease. Aliment Pharmacol Ther. 2018;48:704–12. https://doi.org/10.1111/apt.14950Oral taurine supplementation reduces painful muscle cramps in patients with cirrhosis.

    Article  CAS  PubMed  Google Scholar 

  68. Shao A, Hathcock JN. Risk assessment for the amino acids taurine, l-glutamine and l-arginine. Regul Toxicol Pharmacol. 2008;50:376–99. https://doi.org/10.1016/j.yrtph.2008.01.004.

    Article  CAS  PubMed  Google Scholar 

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  1. Department Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia

    Helen Vidot

  2. The Anzac Research Institute, Hospital Road, Concord, NSW, 2139, Australia

    Nicholas A. Shackel

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Vidot, H., Shackel, N.A. Nutritional Supplementation for Patients with Decompensated Cirrhosis. Curr Hepatology Rep 20, 53–60 (2021). https://doi.org/10.1007/s11901-021-00561-1

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