July 25, 2013

Nutritional Management of Patients with Cirrhosis and Hepatic Encephalopathy

July 19, 2013

Atif Zaman, MD, MPH reviewing Amodio P et al. Hepatology 2013 Jul.

Consensus recommendations are now available despite continued knowledge gaps in this area.

An expert panel commissioned by the International Society for Hepatic Encephalopathy and Nitrogen Metabolism has recommended that all patients with cirrhosis and hepatic encephalopathy should receive nutritional management similar to that for patients with cirrhosis but without hepatic encephalopathy. Specific recommendations from their consensus document are described below.

Strongest recommendations:

  • All patients should undergo baseline nutritional assessment as a part of management. (The authors acknowledged that no clinically practical, well-validated tools to assess nutrition are currently available.)
  • Optimal daily energy intake should be 35 to 40 kcal/kg ideal body weight.
  • Optimal daily protein intake should be 1.2 to 1.5 g/kg ideal body weight.
  • Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrate are ideal.
  • Hyponatremia should always be corrected slowly.

Recommendations with less certainty, but with moderate evidence:

  • Encourage a diet rich in vegetable and daily protein.
  • Branched-chain amino acid supplementation might allow recommended nitrogen intake to be maintained in patients intolerant of dietary protein.
  • A 2-week course of a multivitamin could be justified in patients with decompensated cirrhosis.
  • Encourage a diet containing 25 to 45 g of fiber daily.
  • Avoid long-term treatment with manganese-containing nutritional formulations.


This thoughtful consensus paper highlights how important it is for clinicians to be cognizant of the nutritional status of their patients with cirrhosis as well as the importance of optimizing daily energy and protein intake in these patients. The panel emphasized that dietary protein restriction is detrimental in this population and should be avoided, yet they observed that this practice is still widespread, which requires urgent attention. They also observed that no evidence shows benefits from zinc supplementation or probiotic use. Finally, the panel noted the continued existence of significant knowledge gaps in nutritional management of patients with cirrhosis that merit further research.

Disclosures for Atif Zaman, MD, MPH at time of publication Speaker’s bureau Bristol-Myers Squibb; Genentech; Gilead; Kadmon; Merck; Salix; Vertex


Amodio P et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism consensus. Hepatology 2013 Jul; 58:325. (http://dx.doi.org/10.1002/hep.26370)

PubMed abstract (Free)


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