title: The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus.
abstract: Nitrogen metabolism plays a major role in the development of hepatic encephalopathy (HE) in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed. The assessment of nutritional status in patients with cirrhosis is problematic. In addition, there are significant sex-related differences in body composition and in the characteristics of tissue loss, which limit the usefulness of techniques based on measures of muscle mass and function in women. Techniques that combine subjective and objective variables provide reasonably accurate information and are recommended. Energy and nitrogen requirements in patients with HE are unlikely to differ substantially from those recommended in patients with cirrhosis per se viz. 35-45 kcal/g and 1.2-1.5g/kg protein daily. Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrates will help minimize protein utilization. Compliance is, however, likely to be a problem. Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended, but tolerance varies considerably in relation to the nature of the staple diet. Branched chain amino acid supplements may be of value in the occasional patient intolerant of dietary protein. Increasing dietary fiber may be of value, but the utility of probiotics is, as yet, unclear. Short-term multivitamin supplementation should be considered in patients admitted with decompensated cirrhosis. Hyponatremia may worsen HE; it should be prevented as far as possible and should always be corrected slowly.
  
  
  CONCLUSIONS
  Effective management of these patients requires an integrated multidimensional approach. However, further research is needed to fill the gaps in the current evidence base to optimize the nutritional management of patients with cirrhosis and HE.
authors.affiliation: Department of Medicine University Hospital of Padua Padova Italy. piero.amodio@unipd.it
authors.forename: Piero
authors.initials: P
authors.lastname: Amodio
authors.forename: Chantal
authors.initials: C
authors.lastname: Bemeur
authors.forename: Roger
authors.initials: R
authors.lastname: Butterworth
authors.forename: Juan
authors.initials: J
authors.lastname: Cordoba
authors.forename: Akinobu
authors.initials: A
authors.lastname: Kato
authors.forename: Sara
authors.initials: S
authors.lastname: Montagnese
authors.forename: Misael
authors.initials: M
authors.lastname: Uribe
authors.forename: Hendrik
authors.initials: H
authors.lastname: Vilstrup
authors.forename: Marsha Y
authors.initials: MY
authors.lastname: Morgan
mesh_terms: D004044:Dietary Proteins / Q000008:administration & dosage; D002149:Energy Intake; D004734:Energy Metabolism; D005260:Female; D006501:Hepatic Encephalopathy / Q000178:diet therapy*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000178:diet therapy*; D062407:Meals; D009584:Nitrogen / Q000008:administration & dosage; D009752:Nutritional Status
chemical_list: D004044:Dietary Proteins; D009584:Nitrogen