What are the dietary protein restrictions for patients with hepatic encephalopathy?

From the Guidelines

Patients with hepatic encephalopathy should not restrict protein intake, but rather consume 1.0-1.5 g of protein per kilogram of body weight per day, with a focus on vegetable and dairy proteins rather than animal proteins, as recommended by the most recent guidelines 1. This approach is supported by the latest evidence, which suggests that protein restriction is detrimental and that patients with hepatic encephalopathy have increased protein requirements to prevent muscle wasting and malnutrition 1. The type of protein ingested may be important, with vegetable and dairy proteins being preferred due to their lower content of aromatic amino acids and higher content of branched-chain amino acids, which are less likely to contribute to encephalopathy symptoms 1. Some key points to consider when managing protein intake in patients with hepatic encephalopathy include:

• Avoiding protein restriction, as it can lead to muscle wasting and malnutrition 1
• Encouraging the consumption of vegetable and dairy proteins, which may be better tolerated than animal proteins 1
• Considering branched-chain amino acid (BCAA) supplementation to improve neuropsychiatric performance and reach recommended nitrogen intake 1
• Providing nutrition through oral intake, nasogastric tube, or parenterally, depending on the patient's ability to eat and their nutritional needs 1 Overall, the goal of protein management in patients with hepatic encephalopathy is to provide adequate nutrition while minimizing the risk of ammonia production and encephalopathy symptoms, and the latest guidelines and evidence support a moderate protein intake with a focus on vegetable and dairy proteins.

From the FDA Drug Label

For the prevention and treatment of portal-systemic encephalopathy, including the stages of hepatic pre-coma and coma. An increase in patients’ protein tolerance is also frequently observed with lactulose therapy.

The dietary protein restriction for patients with hepatic encephalopathy is not directly stated in the drug label.

• The label mentions an increase in patients’ protein tolerance with lactulose therapy, but does not provide specific dietary protein restrictions. 2

From the Research

Dietary Protein Restrictions for Hepatic Encephalopathy

• The traditional approach to managing hepatic encephalopathy has involved restricting dietary protein intake, but recent studies suggest that this may not be necessary or beneficial 3, 4, 5.
• A study published in the Journal of Hepatology found that cirrhotic patients with episodic hepatic encephalopathy who received a normal protein diet had similar outcomes to those who received a low-protein diet, and that protein restriction may worsen nutritional status without improving hepatic encephalopathy 3.
• Another study published in Nutrition in Clinical Practice found that most patients with hepatic encephalopathy can tolerate a normal amount of dietary protein without developing worsening symptoms, and that protein-calorie malnutrition is a common complication of chronic liver disease that can be exacerbated by protein restriction 4.
• Some studies have suggested that branched-chain amino acid (BCAA) supplementation may be beneficial for patients with hepatic encephalopathy, particularly those who are intolerant of standard protein diets 6, 7.
• However, the evidence for the use of BCAA supplementation is not consistent, and more research is needed to determine its effectiveness 7.
• Vegetable protein-based diets may be a viable alternative for patients with hepatic encephalopathy who are intolerant of animal protein 4, 5.
• Overall, the current evidence suggests that dietary protein restriction is not necessary for patients with hepatic encephalopathy, and that a balanced diet that includes adequate protein and calories is essential for maintaining nutritional status and preventing complications 3, 4, 5.