It is important to optimize the protein intake in end stage liver disease as malnutrition is common in patients with cirrhosis of liver and is associated with higher morbidity and mortality, said Dr. P. Nagaraja Rao, Department of Gastroenterology, Hepatology and Nutrition, CARE Hospital, Hyderabad.

The primary goal of nutritional support in patients with end stage liver disease is to provide necessary nutrients enough to maintain a positive nitrogen balance without precipitating encephalopathy or other metabolic abnormalities.

Treatment guidelines include prevention of hypoglycemia, providing moderate fats and proteins, restriction of salt and fluid intake and providing vitamin supplementation.

Intra venous nutrition is often not required in patients with cirrhosis of liver. The gut function is generally adequate for providing nutrition by the enteral route rather than parenteral route. Parenteral route is sometimes required in the patients where there is compromised gut function with variceal bleed, after abdominal surgery and paralytic ileus due to intra abdominal sepsis.

At times tolerance to enteral feeding is reduced in these patients. For many years, it was felt that intravenous lipid infusions were contraindicated in patients with liver disease. It is now clear that if liver disease patients require parenteral nutrition there is no contraindication to provide energy as glucose, fat and amino acid solutions.

Energy and protein balance can be maintained by providing 30-40 kcal/kg/day. Daily intake of approximately 0.8 – 1.3 g/kg is required to maintain nitrogen equilibrium. Energy expenditure is also increased in some patients with advanced disease.

Patients with cirrhosis will tolerate high protein, high calorie diets without any fear of precipitating encephalopathy, renal insufficiency or fluid retention, he averred.