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Hepatic encephalopathy: dietary therapy 377Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 4circumference (MAMC), but not with tricepsskinfold thickness (TST).In a randomized, double-blind,multicenter study, comparing a supplementof BCAA or maltodextrin the conclusionswere that the supplementation with BCAAafter an episode of HE does not decreaserecurrence of HE. BCAA improve minimalHE and muscle mass [16].The timing of BCAA supplementationmay be crucial. This issue was addressed bya crossover study. At 3 months, a significantincrease in serum albumin level wasobserved in patients administered nocturnalBCAA.It leads to an increase of serum proteinof approximately 10% if given beforebedtime [17]. Problems that limit the use ofBCAA in the treatment of HE are their tasteand expense.Our study shows that protein andenergy requirements for cirrhotic patientsmay be maintained in patients with HE. Itleads to improvement of mental status in90% of patients. Our study confirms recentstudies showing that patients tolerate highproteindiets and benefit of them.Most patients tolerate HPHC dietwithout risk of HE. It improves mental statusin a significant way. A higher proportion ofpatients with severe impairment of themental status improved after one month diet(63%). A lower proportion of patients withalcoholic cirrhosis improved their mentalstatus compared with those with viral ormixed etiology. A significant improvementof number connection test (NCT) scores wasalso noted after the diet.A decrease in blood ammonia levelwas noted not only for patients withimprovement of mental status, but also forthe patients that maintained their mentalstatus. No one had an increase of serumlevel ammonia. This HPHC diet had asignificant improvement on the body weightand mid arm muscle circumference(MAMC) after a month of treatment.We used an eating schedulecharacterized by 4 meals during the daytimea a late evening snack consisting in foodreach in carbohydrates. Like similar studiesthat referred to reach in BCAA late eveningsnacks diets, this study shows a betteroutcome from the mental status andnutritional point of view.CONCLUSIONHigh protein high calorie diet had abeneficial effect on the patients withcirrhosis and hepatic encephalopathy. Thiseffect was statistically significant regardingthe mental status, level of the serumammonia and the body weight.The daily eating pattern consisting in 4meals and l late evening snack contributed toHE improvement, avoiding protein loadingin a period of day, but maintaining theprotein positive balance.CONFLICT OF INTERESTSNone to declare.REFERENCES1. Krenitski J. Nutrition for Patients with HepaticFailure. Practical Gastroenterology. 2003; 6:23-42.2. Charlton M. Branched-Chain Amino AcidEnriched Supplements as Therapy for LiverDisease. The Journal of Nutriton. 2006; 136:295S-298S.3. Parrish CR, Krenitsky J, McCray S. HepaticModule. University of Virginia Health SystemNutrition Support Traineeship Syllabus.Available through the University of VirginiaHealth System Nutrition Services in January2003.4. Alberino F, Gatta A, Amodio P, et al.Nutrition and survival in patients with livercirrhosis. Nutrition 2001; 17: 445–450.5. O’Brien A, Williams R. Nutrition in end-stageliver disease: priciples and practice.Gastroenterology. 2008; 134: 1729-1740.6. Munoz SJ. Hepatic encephalopathy. Med ClinNorth Am. 2008; 92(4): 795-812.7. Bajaj JS, Cordoba J, Mullen P, et al. Reviewarticle: the design of clinical trials in hepaticencephalopathy. Aliment Pharmacol Ther.2011; 33: 739-747.8. Chadalavada R, Biyyani RS, Maxwell J,Mullen K. Nutrition in hepaticencephalopathy. Nutr Clin Pract. 2010; 25(3):257-264.
378 Teiuşanu A. et al.Jurnalul de Chirurgie (Iaşi), 2012, Vol. 8, Nr. 49. Plauth M, Cabré E, Riggio O, Assis-CamiloM, Pirlich M, Kondrup J; DGEM (GermanSociety for Nutritional Medicine), Ferenci P,Holm E, Vom Dahl S, Müller MJ, Nolte W;ESPEN (European Society for Parenteral andEnteral Nutrition). ESPEN guidelines onenteral nutrition: liver disease. Clin Nutr.2006; 25(2): 285-294.10. Bemeur C, Desjardins P, Butterforth R. Roleof nutrition in the management of hepaticencephalopathy in end-stage liver failure. JNutr Metab. 2010;2010:489823.11. Plauth M, Cabré E, Campillo B, Kondrup J,Marchesini G, Schütz T, Shenkin A, WendonJ; ESPEN. ESPEN guidelines on ParenteralNutrition: hepatology. Clin Nutr. 2009; 28(4):436-444.12. Merli M, Riggio O. Dietary and nutritionalindications in hepatic encephalopathy. MetabBrain Dis. 2009; 24(1): 211-221.13. Frederick RT. Current concepts in thepathophysiology and management of hepaticencephalopathy. Gastroenterol Hepatol (NY).2011; 7(4): 222-233.14. Als-Nielsen B, Koretz RL, Kjaergard LL.Branched chain amino acids for hepaticencephalopathy. Cochrane Database Syst Rev.2003; 2: CD001939.15. Nakaya Y, Okita K, Suzuki K, et al. BCAAenrichedsnak improves nutritional state ofcirrhosis. Nutrition. 2007; 23: 113-120.16. Les I, Doval E, Martinez RG, et al. Effects ofbranched-chain amino acids supplementationin patients with cirrhosis and a previousepisode of hepatic encephalopathy: arandomized study. Am J Gastroenterol. 2011;106: 1081-1088.17. Khanna S, Gopalan S. Role of branched-chainamino acids in liver disease. Curr Opin ClinNutr Metab Care. 2007; 10(3): 297-303.
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