Nuove frontiere della nutrizione clinica nell’insufficienza epatica

Protein-energy malnutrition is a common finding in patients with liver cirrhosis, ranging from 10% to 100% in relation to disease severity and etiology and associated with long-term prognosis. Patients with advanced liver disease should be recommended diets providing adequate calories, proteins, vitamins and micronutrients. Recent studies have shown that cirrhotic patients tolerate a normal amount of protein without any deleterious effect on mental state, and nutritional support is only indicated in patients with a low spontaneous intake. The diet should provide at least 1.2 times the estimated daily resting energy expenditure (at least 30 kcal/kg b.w.), 30-35% of total energy as fat and at least 1 gr/kg protein, unless severe hepatic encephalopathy is present. Under these conditions, vegetable proteins should be preferred as, by increasing intraluminal pH, decreasing transit time and enhancing ammonia excretion, they have beneficial effects on hepatic encephalopathy. Amino acid supplements are recommended in order to prevent excessive protein catabolism. Branched-chain amino acid (BCAA) supplementation is effective in down-regulating protein metabolism and in improving nitrogen balance, and the use of oral BCAAs is supported by a few large multicenter, randomized controlled trials. The incidence of events (death and progression to liver failure) is reduced and quality of life is improved, possibly through a mechanism involving liver regeneration, via hepatocyte growth factor production.