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Side Bar to Andiamo’s Side Effects Poll: The Protein Debate
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Side Bar to Andiamo’s Side Effects Poll: The Protein Debate

Topic:  Nutrition, Protein, and Chronic Liver Disease
There has been some discussion of late about the advisability of a high-protein diet in people with chronic liver disease, and this post is relative to that discussion and those looking for recent evidence against protein restriction in the setting of cirrhosis:

Nutrition in Hepatic Encephalopathy
Author(s): Chadalavada, R, Biyyani, RSS, Maxwell, J, Mullen, K.
Citation: Nutrition In Clinical Practice 25 (3): 257-264 Jun 2010 Year: 2010
Abstract: “Protein calorie malnutrition (PCM) is a well-known complication of chronic liver disease (CLD). A major contribution to PCM in CLD is restriction of dietary protein intake. After many decades of injudicious reduction in dietary protein, cirrhotic patients are now prescribed appropriate amounts of protein. PCM in CLD is known to be associated with life-threatening complications. In the general approach to these patients, the initial and most important step for the clinician is to recognize the extent of malnutrition. Most patients tolerate a normal amount of dietary protein without developing hepatic encephalopathy (HE). Oral branched-chain amino acids (BCAAs) have a limited role in HE. Patients who exhibit dietary protein intolerance originally were thought to be best treated with BCAA formulations. Mixed evidence has been reported in multiple studies. In keeping with other reports, this article shows that in animal protein intolerant patients, even those with advanced cirrhosis, vegetable protein based diets are well tolerated. Another approach to management of apparent dietary intolerance is to optimize HE treatment with available medications. This article reviews the causes of HE, minimal HE, and PCM; examines nutrition requirements and assessment; and discusses treatment options for malnutrition in HE.”

The article above referenced other data addressing protein more specifically:

Improvement of hepatic encephalopathy using a modified high-calorie high-protein diet.
Author(s) Gheorghe L, Iacob R, Vădan R, Iacob S, Gheorghe C.
Rom J Gastroenterol. 2005 Sep;14(3):231-8.
BACKGROUND AND AIM: Protein-calorie malnutrition (PCM) occurs in 20-60% of patients with hepatic cirrhosis and is associated with the development of life-threatening complications. We evaluated the effect of a modified, casein-vegetable-based, high-protein high-calorie (HPHC) diet on the outcome of cirrhotic patients with hepatic encephalopathy (HE).
METHODS: One hundred and fifty three consecutive cirrhotic patients with overt HE were included in this study. An HPHC diet based on better-tolerated vegetable and milk-derived proteins was initiated in order to ensure the adequate protein-energy requirements of 30 kcal/kg/day and 1.2g proteins/kg/day. Serial (daily) assessments were done, including mental status, asterixis, a conventional Number Connection Test (NCT), bowel movements and blood ammonia level. The assessment of the mental status was performed using the West Haven scale. Favorable evolution or response to HPHC diet was defined as an improvement in HE stage with 1 or more (Delta > or =1 stage) after 14 days of diet.
RESULTS: During the HPHC diet, 122 patients (79.7%) improved in terms of response definition. A significant decrease in blood ammonia level was observed after 14 days (p<0.0001) in all patients, whatever the improvement of the mental status. A significant improvement in the NCT scores was also noted (p<0.0001). More patients with advanced HE (West Haven stage 3) precipitated by various factors showed a Delta = -2 improvement of their mental status during the modified HPHC diet compared with patients in lower initial stages (50% vs 18.9%, p=0.002). More patients in Child-Pugh B class had a Delta = -2 decrease in the grade of HE compared with patients in Child-Pugh C class (61.7% vs. 14%, p=0.001).
CONCLUSIONS: Almost 80% of patients in our study improved their mental status during the casein-vegetable-based HPHC diet, showing that dietary protein restriction is not required for the improvement of HE. A higher rate of improvement was noted in patients with severe impairment of mental status related to precipitating factors and in patients with well preserved liver function. The daily eating pattern consisting of 4 snack-meals and a late evening meal may contribute to HE improvement by equal protein distribution during the day.

Normal protein diet for episodic hepatic encephalopathy: results of a randomized study.
Author(s): Córdoba J, López-Hellín J, Planas M, Sabín P, Sanpedro F, Castro F, Esteban R, Guardia J.
J Hepatol. 2004 Jul;41(1):38-43.
BACKGROUND/AIMS: Protein-restricted diets are usually prescribed for cirrhotic patients with hepatic encephalopathy. However, protein restriction may worsen the nutritional status without resulting in an improvement of hepatic encephalopathy. We designed a study to assess the effects of the amount of protein in the diet on the evolution of episodic hepatic encephalopathy.
METHODS: Cirrhotics admitted to the hospital because of an episode of encephalopathy (n=30) were randomized to receive a low-protein diet with progressive increments or a normal protein diet for 14 days, in addition to standard measures to treat hepatic encephalopathy. Protein synthesis and breakdown were studied at day 2 and day 14 with the glycine-N(15) infusion method.
RESULTS: The outcome of hepatic encephalopathy was not significantly different between both groups of treatment. Protein synthesis was similar for low and normal protein diet, but those of the low-protein diet group showed higher protein breakdown.
CONCLUSIONS: Diets with a normal content of protein, which are metabolically more adequate, can be administered safely to cirrhotic patients with episodic hepatic encephalopathy. Restriction of the content of protein of the diet does not appear to have any beneficial effect for cirrhotic patients during an episode of encephalopathy.

Dietary protein intakes in patients with hepatic encephalopathy and cirrhosis: current practice in NSW and ACT.
Authors:  Heyman JK, Whitfield CJ, Brock KE, McCaughan GW, Donaghy AJ.
Med J Aust. 2006 Nov 20;185(10):542-3.
OBJECTIVE: To ascertain whether current practice in teaching hospitals in New South Wales and the Australian Capital Territory delivers adequate dietary protein in the management of malnutrition in adults with cirrhosis, in accordance with European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for nutrition in liver disease.
STUDY DESIGN: Cross-sectional study of dietitians using a self-administered, mail-back survey.
SETTING: Teaching hospitals in NSW and the ACT treating patients with cirrhosis.
PARTICIPANTS: Dietitians seeing patients with cirrhosis in the 12 months prior to completing the survey.
MAIN OUTCOME MEASURES: Current dietary protein prescription practice for patients with cirrhosis (with and without hepatic encephalopathy); use of nutritional supplements and enteral feeding for malnourished patients with cirrhosis.
RESULTS: Dietitians following the ESPEN guidelines were in the minority: 36% of the dietitians recommended an adequate protein intake for patients with hepatic encephalopathy. Sixty-four per cent of the dietitians had received referrals from the medical team requesting inappropriate protein-restricted diets for patients without hepatic encephalopathy. Seventy-eight per cent of the dietitians requested clarification of the recommended nutritional management of patients with cirrhosis.
CONCLUSION: Many medical and dietetic staff inappropriately restrict protein intake of patients with cirrhosis.

Related Discussions
I meet with the Dietitian at Yale-New Haven Transplant Center this week. It is part of the process for getting listed for a liver transplant here. Here are a few thoughts related to protein and HE that we discussed…

The Dietitian recommended 5 or 6 small meals with protein each day. This diet helps to prevent muscle wasting and maximum energy distribution in End-Stage Liver Disease. It also helps to maintain blood sugar levels for energy usage. As you all know, advanced liver disease causes constant debilitating fatigue. This is because the damaged liver is unable to store and distribute the extra energy from large meals. You want to obtain your energy and nutrition consistently throughout the day and right before going to sleep.

Albumin is a protein produced in the liver that carriers nutrients around the body and helps to maintain fluid balance. In advanced disease, the liver has decreased ability to maintain blood protein levels. So adequate moderate protein level should be maintained. Non meat proteins such as dairy, beans, and nuts and eggs should be eaten to get adequate moderate protein. Red meats are believed to be the biggest generator of ammonia in patients with hepatic encephalopathy. For those with decompensated cirrhosis caused by HCV it is common for patients to have HE so it is important to know about dietary issues.

For without the complication of HE, a high protein diet is appropriate.

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