Skip to main content
SpringerLink
Log in

Nutrition Support of Patients with Cirrhosis

  • Chapter
  • First Online:
Surgical Procedures on the Cirrhotic Patient

  • 1165 Accesses

Abstract

Malnutrition is prevalent among individuals with cirrhosis and has adverse effects on patient outcomes. Prompt attention to assessment of nutrition status to determine cause and degree of malnutrition is the first step in implementing a nutrition plan. Nutrition status can be assessed using a combination of parameters although Subjective Global Assessment is most commonly utilized. CT and MRI scans can also be used to quantify muscle and fat stores but are not frequently used in a clinical setting. Cirrhosis can cause metabolic aberrations affecting the metabolism, storage, and utilization of protein, carbohydrate, and fat. Electrolyte abnormalities and micronutrient deficiencies can ensue and may require supplementation or restriction. Because oral intake is frequently inadequate, nutrition support may be required with enteral nutrition as the preferred option. This chapter provides recommendations for nutrient needs and delivery in patients with cirrhosis considering the symptoms and complications of liver disease.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Andus T. ESPEN guidelines on enteral nutrition: liver disease – tube feeding (TF) in patients with esophageal varices is not proven to be safe. Clin Nutr. 2007;26(2):272; author reply 273–4.

    Google Scholar 

  2. Baltz JG, Argo CK, Al-Osaimi AM, Northup PG. Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series. Gastrointest Endosc. 2010;72(5):1072–5. doi:10.1016/j.gie.2010.06.043.

    Article  PubMed  Google Scholar 

  3. Bémeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological complications. J Clin Exp Hepatol. 2014;4(2):141–50. doi:10.1016/j.jceh.2013.05.008.

    Article  PubMed  Google Scholar 

  4. Córdoba J, López-Hellín J, Planas M, Sabín P, Sanpedro F, Castro F, Esteban R, Guardia J. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol. 2004;41(1):38–43.

    Article  PubMed  Google Scholar 

  5. Corey KE, Cohen DE. Lipid and lipoprotein metabolism in liver disease. In: De Groot LJ, Chrousos G, Dungan K, et al. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000–2015 Jun 27. Available from: https://www.ncbi.nlm.nih.gov/books/NBK326742/. Accessed 28 Sept 2016.

  6. Crippin JS. Is tube feeding an option in patients with liver disease? Nutr Clin Pract. 2006;21(3):296–8.

    Article  PubMed  Google Scholar 

  7. Crook MA. Refeeding syndrome: problems with definition and management. Nutrition. 2014;30(11–12):1448–55. doi:10.1016/j.nut.2014.03.026.

    Article  PubMed  Google Scholar 

  8. Cruz Jr RJ, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Fontes P, DiMartini A. Objective radiologic assessment of body composition in patients with end-stage liver disease: going beyond the BMI. Transplantation. 2013;95(4):617–22. doi:10.1097/TP.0b013e31827a0f27.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8–13.

    Article  CAS  PubMed  Google Scholar 

  10. Dreyer HC, Drummond MJ, Pennings B, Fujita S, Glynn EL, Chinkes DL, Dhanani S, Volpi E, Rasmussen BB. Leucine-enriched essential amino acid and carbohydrate ingestion following resistance exercise enhances mTOR signaling and protein synthesis in human muscle. Am J Physiol Endocrinol Metab. 2008;294(2):E392–400.

    Article  CAS  PubMed  Google Scholar 

  11. Drummond MJ, Rasmussen BB. Leucine-enriched nutrients and the regulation of mammalian target of rapamycin signalling and human skeletal muscle protein synthesis. Curr Opin Clin Nutr Metab Care. 2008;11(3):222–6. doi:10.1097/MCO.0b013e3282fa17fb.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, Holcombe SA, Wang SC, Segev DL, Sonnenday CJ. Sarcopenia and mortality after liver transplantation. J Am Coll Surg. 2010;211(2):271–8. doi:10.1016/j.jamcollsurg.2010.03.039.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Fukui H, Saito H, Ueno Y, Uto H, Obara K, Sakaida I, Shibuya A, Seike M, Nagoshi S, Segawa M, Tsubouchi H, Moriwaki H, Kato A, Hashimoto E, Michitaka K, Murawaki T, Sugano K, Watanabe M, Shimosegawa T. Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol. 2016;51(7):629–50.

    Article  CAS  PubMed  Google Scholar 

  14. Gluud LL, Dam G, Les I, Córdoba J, Marchesini G, Borre M, Aagaard NK, Vilstrup H. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev. 2015;(2): CD001939. doi: 10.1002/14651858.CD001939.pub3.

  15. Gottschall CB, Pereira TG, Rabito EI. Álvares-Da-Silva MR4. Nutritional status and dietary intake in non-cirrhotic adult chronic hepatitis C patients. Arq Gastroenterol. 2015;52(3):204–9.

    Article  PubMed  Google Scholar 

  16. Grancini V, Trombetta M, Lunati ME, Zimbalatti D, Boselli ML, Gatti S, Donato MF, Resi V, D’Ambrosio R, Aghemo A, Pugliese G, Bonadonna RC, Orsi E. Contribution of β-cell dysfunction and insulin resistance to cirrhosis-associated diabetes: role of severity of liver disease. J Hepatol. 2015;63(6):1484–90. doi:10.1016/j.jhep.2015.08.011.

    Article  CAS  PubMed  Google Scholar 

  17. Hasse J, Gautam M, Saracino G, Jennings L. Malnutrition reduces survival in patients awaiting liver transplantation. (Abstract) Presented at American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week. 2015. http://pen.sagepub.com/content/suppl/2015/01/28/39.2.231.DC1/Clinical_Nutrition_Week_2015_Paper_Sessions_REV.pdf. Accessed 19 Sep 2016.

  18. Hasse J, Strong S, Gorman MA, Liepa G. Subjective global assessment: alternative nutrition-assessment technique for liver-transplant candidates. Nutrition. 1993;9(4):339–43.

    CAS  PubMed  Google Scholar 

  19. Hasse JM, DiCecco SR. Enteral nutrition in chronic liver disease: translating evidence into practice. Nutr Clin Pract. 2015;30(4):474–87. doi:10.1177/0884533615591058.

    Article  PubMed  Google Scholar 

  20. Holecek M. Evidence of a vicious cycle in glutamine synthesis and breakdown in pathogenesis of hepatic encephalopathy-therapeutic perspectives. Metab Brain Dis. 2014;29(1):9–17. doi:10.1007/s11011-013-9428-9.

    Article  CAS  PubMed  Google Scholar 

  21. Kaido T, Ogawa K, Fujimoto Y, et al. Impact of sarcopenia on survival in patients undergoing living donor liver transplantation. Am J Transplant. 2013;13(6):1549–56.

    Article  CAS  PubMed  Google Scholar 

  22. Krell RW, Kaul DR, Martin AR, Englesbe MJ, Sonnenday CJ, Cai S, Malani PN. Association between sarcopenia and the risk of serious infection among adults undergoing liver transplantation. Liver Transpl. 2013;19(12):1396–402. doi:10.1002/lt.23752.

    Article  PubMed  Google Scholar 

  23. Kynci JA, Chodash HB, Tsang T-K. PEG in a patient with ascites and varices. Gastrointest Endosc. 1995;42(1):100–1.

    Article  CAS  PubMed  Google Scholar 

  24. Leise MD, Poterucha JJ, Kamath PS, Kim WR. Management of hepatic encephalopathy in the hospital. Mayo Clin Proc. 2014;89(2):241–53. doi:10.1016/j.mayocp.2013.11.009.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Löser C, Aschl G, Hébuterne X, et al. ESPEN guidelines on artificial enteral nutrition-percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24:848–61.

    Article  PubMed  Google Scholar 

  26. McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG clinical guideline: nutrition therapy in the adult hospitalized patient. Am J Gastroenterol. 2016;111(3):315–34. quiz 335 doi:10.1038/ajg.2016.28.

    Article  CAS  PubMed  Google Scholar 

  27. McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, Mc Carthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C, Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. doi:10.1177/0148607115621863.

    Article  CAS  PubMed  Google Scholar 

  28. Metcalfe EL, Avenell A, Fraser A. Branched-chain amino acid supplementation in adults with cirrhosis and porto-systemic encephalopathy: systematic review. Clin Nutr. 2014;33(6):958–65. doi:10.1016/j.clnu.2014.02.011.

    Article  CAS  PubMed  Google Scholar 

  29. Meza-Junco J, Montano-Loza AJ, Baracos VE, Prado CM, Bain VG, Beaumont C, Esfandiari N, Lieffers JR, Sawyer MB. Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma. J Clin Gastroenterol. 2013;47(10):861–70. doi:10.1097/MCG.0b013e318293a825.

    Article  PubMed  Google Scholar 

  30. Montano-Loza AJ. Clinical relevance of sarcopenia in patients with cirrhosis. World J Gastroenterol. 2014a;20(25):8061–71.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Montano-Loza AJ. Muscle wasting: a nutritional criterion to prioritize patients for liver transplantation. Curr Opin Clin Nutr Metab Care. 2014b;17(3):219–25. doi:10.1097/MCO.0000000000000046.

    Article  PubMed  Google Scholar 

  32. Montano-Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, Sawyer MB. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2012;10(2):166–73, 173.e1. doi:10.1016/j.cgh.2011.08.028.

    Article  PubMed  Google Scholar 

  33. O’Shea RS, Dasarathy S, McCullough AJ. Practice Guideline Committee of the American Association for the Study of Liver. Alcoholic liver disease. Hepatology. 2010;51(1):307–28.

    Article  PubMed  Google Scholar 

  34. Parli SE, Ruf KM, Magnuson B. Pathophysiology, treatment, and prevention of fluid and electrolyte abnormalities during refeeding syndrome. J Infus Nurs. 2014;37(3):197–202. doi:10.1097/NAN.0000000000000038.

    Article  PubMed  Google Scholar 

  35. Phillips MS, Ponsky JL. Overview of enteral and parenteral feeding access techniques: principles and practice. Surg Clin North Am. 2011;91(4):897–911.

    Article  PubMed  Google Scholar 

  36. Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr. 2006;25(2):285–94.

    Article  CAS  PubMed  Google Scholar 

  37. Runyon BA. Practice guideline: management of adult patients with ascites due to cirrhosis. Update. 2012. AASLD website. http://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf. Accessed 25 Sept 2016.

  38. Sasidharan M, Nistala S, Narendhran RT, Murugesh M, Bhatia SJ, Rathi PM. Nutritional status and prognosis in cirrhotic patients. Trop Gastroenterol. 2012;33(4):257–64.

    Article  PubMed  Google Scholar 

  39. Schlein K. Gastric versus small bowel feeding in critically ill adults. Nutr Clin Pract. 2016;31(4):514–22.

    Article  PubMed  Google Scholar 

  40. Shangraw RE, Rabkin JM, Lopaschuk GD. Hepatic pyruvate dehydrogenase activity in humans: effect of cirrhosis, transplantation, and dichloroacetate. Am J Physiol. 1998;274(3 Pt 1):G569–77.

    CAS  PubMed  Google Scholar 

  41. Skipper A. Refeeding syndrome or refeeding hypophosphatemia: a systematic review of cases. Nutr Clin Pract. 2012;27(1):34–40. doi:10.1177/0884533611427916.

    Article  PubMed  Google Scholar 

  42. Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, Shaheen AA, Qamar H, Mansoor N, Carbonneau M, Ismond K, Mann S, Alaboudy A, Ma M. A model to identify sarcopenia in patients with cirrhosis. Clin Gastroenterol Hepatol. 2016;14(10):1473–1480.e3. pii: S1542-3565(16)30198-7 doi:10.1016/j.cgh.2016.04.040.

    Article  PubMed  Google Scholar 

  43. Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, Esfandiari N, Baracos V, Montano-Loza AJ, Myers RP. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl. 2012;18(10):1209–16. doi:10.1002/lt.23495.

    Article  PubMed  Google Scholar 

  44. Teiusanu A, Andrei M, Arbanas T, Nicolaie T, Diculescu M. Nutritional status in cirrhotic patients. Maedica (Buchar). 2012;7(4):284–9.

    Google Scholar 

  45. Tsien C, Davuluri G, Singh D, Allawy A, Ten Have GA, Thapaliya S, Schulze JM, Barnes D, McCullough AJ, Engelen MP, Deutz NE, Dasarathy S. Metabolic and molecular responses to leucine-enriched branched chain amino acid supplementation in the skeletal muscle of alcoholic cirrhosis. Hepatology. 2015;61(6):2018–29. doi:10.1002/hep.27717.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Vieira PM, De-Souza DA, Oliveira LC. Nutritional assessment in hepatic cirrhosis; clinical, anthropometric, biochemical and hematological parameters. Nutr Hosp. 2013;28(5):1615–21. doi:10.3305/nh.2013.28.5.6563.

    PubMed  Google Scholar 

  47. Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, Weissenborn K, Wong P. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715–35. doi:10.1002/hep.27210.

    Article  PubMed  Google Scholar 

  48. Yarze JC. Peritonitis after PEG placement in patients with cirrhotic ascites. Gastrointest Endosc. 2011;73(5):1071.

    Article  PubMed  Google Scholar 

  49. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73–84. doi:10.1002/hep.28431.

    Article  PubMed  Google Scholar 

  50. Zhu GQ, Shi KQ, Huang S, Wang LR, Lin YQ, Huang GQ, Chen YP, Braddock M, Zheng MH. Systematic review with network meta-analysis: the comparative effectiveness and safety of interventions in patients with overt hepatic encephalopathy. Aliment Pharmacol Ther. 2015;41(7):624–35. doi:10.1111/apt.13122.

    Article  CAS  PubMed  Google Scholar 

  51. Ukleja A, Freeman KL, Gilbert K, Kochevar M, Kraft MD, Russell MK, Shuster MH, Task force on standards for nutrition support: adult hospitalized patients, and the American Society for parenteral and enteral nutrition board of directors. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403–14. doi:10.1177/0884533610374200.

    Article  PubMed  Google Scholar 

  52. Hasse JM. Nutrition assessment and support of organ transplant recipients. JPEN J Parenter Enteral Nutr. 2001;25:120–31.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth Street, Suite 950, Dallas, TX, 75246, USA

    Jeanette Hasse PhD, RD, LD, FADA, CNSC

  2. Department of Internal Medicine, Texas A&M College of Medicine, Bryan, TX, 77807, USA

    Manjushree Gautam MD, MAS

  3. Simmons Transplant Institute, Baylor All Saints Medical Center, 1250 8th Avenue, Suite 515, Fort Worth, TX, 76104, USA

    Manjushree Gautam MD, MAS

Authors
  1. Jeanette Hasse PhD, RD, LD, FADA, CNSC
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Manjushree Gautam MD, MAS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeanette Hasse PhD, RD, LD, FADA, CNSC .

Editor information

Editors and Affiliations

  1. Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA

    Bijan Eghtesad

  2. Department of Surgery, University of Chicago, Chicago, Illinois, USA

    John Fung

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing AG

About this chapter

Cite this chapter

Hasse, J., Gautam, M. (2017). Nutrition Support of Patients with Cirrhosis. In: Eghtesad, B., Fung, J. (eds) Surgical Procedures on the Cirrhotic Patient. Springer, Cham. https://doi.org/10.1007/978-3-319-52396-5_6

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-52396-5_6

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-52394-1

  • Online ISBN: 978-3-319-52396-5

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation