【文章內(nèi)容簡介】 6: 4355 Nutritional Management of End Stage Liver Disease Energy ? Energy expenditure: currently there are no metabolic equations which are able to estimate accurately the energy requirements of the patient with ESLD. ? HarrisBenedict, Schofields and Muller all underestimate the energy requirements of this group ? Indirect calorimetry Nutritional Management of End Stage Liver Disease Glycogen storage ? Reduced glycogen storage capacity ? Unable to tolerate periods of prolonged fasting – increased protein breakdown in periods of prolonged fasting Nutritional Management of End Stage Liver Disease Fat ? Altered fat synthesis ? Lipids are oxidised as a preferential substrate ? Increased lipolysis ? Active mobilisation of lipid stores Depensated Liver Disease ? Fat restriction contraindicated in most patients ? Symptoms of fat intolerance such as steatorrhoea, abdominal pain or nausea following a high fat intake are rare. If present fat modification may be necessary Nutritional Management of End Stage Liver Disease Protein ? Protein turnover in cirrhotic patients is normal or increased ? Stable cirrhotics have increased protein requirements185。?178。 ? Stable cirrhotic patients are capable of achieving positive nitrogen balance during aggressive nutritional support regime185。?178。 185。Kondrup J, Neilsen K et al. Effect of long term refeeding on protein metabolism in patients with cirrhosis of the liver. Br J Nutr 1997。 77: 197212 178。Swart, GR et all. Minimal protein requirements in liver cirrhosis determined by nitrogen balance measurements at three levels of protein intake. Clin Nutr 1989。 8: 329336 Nutritional Management of End Stage Liver Disease Protein ? Protein turnover in cirrhotic patients is normal or increased ? Stable cirrhotics have increased protein requirements185。?178。 ? Stable cirrhotic patients are capable of achieving positive nitrogen balance during aggressive nutritional support regime185。?178。 185。Kondrup J, Neilsen K et al. Effect of long term refeeding on protein metabolism in patients with cirrhosis of the liver. Br J Nutr 1997。 77: 197212 178。Swart, GR et all. Minimal protein requirements in liver cirrhosis determined by nitrogen balance measurements at three levels of protein intake. Clin Nutr 1989。 8: 329336 Nutritional Management of End Stage Liver Disease Protein ? Protein refeeding showed a 30% increase in protein synthesis* ? Protein refeeding did not show a significant increase in protein degradation* *Kondrup J, Neilsen, K,and Anders J. Effect of long term refeeding on protein metabolism in patients with cirrhosis of the liver. Br J Nutrition (1997), 77, 197212 Nutritional Management of End Stage Liver Disease Protein ? Patients with cirrhosis have been shown to have high protein requirements to maintain positive nitrogen balance* *Konrup J, Nielsen K, Juul A. Effect of longterm refeeding on protein metabolism in patients with cirrhosis of the liver. Br. J. Nutr. 1997。 77: 197212 Nutritional Management of End Stage Liver Disease Protein ? The protein restricted diets used traditionally have probably arisen historically from the response to a dietary protein load seen in cirrhotic patients who have some form of portocaval shunt surgery Nutritional Management of End Stage Liver Disease Protein requirements in episodic hepatic encephalopathy ? 62 patients with acute encephalopathy assessed – 32 excluded ? 30 patients randomised into two groups ? All patients received lactulose enema and then identical oral neomycin dosage Cordoba J, LopezHellin J et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomised study. J of Hepatology 41 2020) 3843 Nutritional Management of End Stage Liver Disease ? 20 patients pleted study ? 5 patients in each arm dropped out – 4 deaths in each. Group A: additional variceal bleed。 group B: additional voluntary abandon Nutritional Management of End Stage Liver Disease ? 2 groups – 15 in each group ? 14 days ? Group A: 0g protein/day for 3 days. Protein increased incrementally to protein/kg/day ? Group B: protein/kg/day ? Protein synthesis and breakdown studied at day 2 and day 14 Nutritional Management of End Stage Liver Disease Day 2: ? Increased protein breakdown in protein restricted group ? No statistically significant difference in protein synthesis Nutritional Management of End Stage Liver Disease Nutritional Management of End Stage Liver Disease Restricting protein intake did not have any positive effect on the evolution of episodic hepatic encephalopathy Nutritional Management of End Stage Liver Disease Protein ? Protein restriction is contra indicated for patients with depensated cirrhosis ? Remended protein intake for cirrhotics is – protein/kg/day185。 ? Dietary protein restriction does not appear to be of any benefit in episodic hepatic encephalopathy178。 185。Plauth M, Merlim, Kondrup J, Weimann A, Ferenci P, Muller Guidelines for nutrition in Liver Disease and Transplantation. Clinical Nutrition 1997。 16: 4355178。 178。Cordoba J, LopezHellin J et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomised study. J of Hepatology 41 2020)