From the Guidelines
For patients with hepatic encephalopathy, a balanced protein diet of 1.2-1.5 g/kg/day is recommended, rather than protein restriction which was previously advised, as supported by the most recent guidelines 1.
Key Recommendations
- Focus on vegetable and dairy proteins which are better tolerated than animal proteins, as suggested by recent studies 1.
- Consume small, frequent meals throughout the day to help the liver process nutrients more efficiently, which is in line with the recommendations for patients with cirrhosis 1.
- Ensure adequate calorie intake (35-40 kcal/kg/day) to prevent muscle breakdown, as muscle plays a crucial role in ammonia removal 1.
- Supplement with branched-chain amino acids (BCAAs) if protein intolerance occurs, as BCAAs may facilitate the provision of an adequate nitrogen intake and improve neuropsychiatric performance 1.
Rationale
The relationship between malnutrition and hepatic encephalopathy (HE) has been well established, with malnourished patients being more prone to developing HE 1. Therefore, nutritional assessment and intervention are crucial in the management of HE. The use of vegetable and dairy proteins, as well as BCAAs, may help improve nutritional status and reduce ammonia levels, ultimately improving patient outcomes 1.
Additional Considerations
- Regular nutritional assessment is important as requirements may change based on disease severity, and patients with HE should undergo an assessment of nutritional status by taking a good dietary history, with anthropometric data and muscle strength measurement as practical, useful measures of nutritional status 1.
- Patients with HE grade III-IV may require nutrition by nasogastric tube or parenterally, as oral dietary intake may be unfeasible or impossible 1.
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 diet advice that can be given to a hepatic encephalopathy patient is to monitor and potentially increase protein tolerance as lactulose therapy may allow for this. However, specific dietary recommendations are not provided in the label. 2
From the Research
Diet Advice for Hepatic Encephalopathy Patients
- Avoid protein restriction in patients with hepatic encephalopathy, as it may lead to malnutrition and worsen the condition 3, 4, 5
- Ensure adequate caloric intake to prevent malnutrition, which is common in patients with liver disease 4, 5
- Consider using vegetable proteins or branched-chain amino acids as an alternative to standard proteins for patients who are protein-sensitive 6, 5
- Nutritional management should take into account the patient's hepatic reserve, severity of hepatic encephalopathy, and current nutritional status 6
- A multi-disciplinary approach with nutritional education, early nutritional risk screening, and repeated dietary counseling is necessary to achieve better outcomes in patients with hepatic encephalopathy 4
Key Considerations
- Protein restriction is not recommended for all patients with hepatic encephalopathy, but may be necessary for selected patients 6
- Branched-chain amino acid supplementation may improve nutritional status and reduce post-injury catabolism 5
- Lactulose and/or rifaximin may be used for the long-term management of hepatic encephalopathy, with lactulose effective for preventing overt HE recurrence and rifaximin reducing the risk of overt HE recurrence and HE-related hospitalization 7