[Nutrition and malnutrition in hepatic cirrhosis]

Liver cirrhosis is associated with malnutrition in 10 to 90% of cases, following different authors. This prompted us to compare our previous studies with recent literature data in order to review this topic from a practical standpoint. Several pathophysiological factors are blamed for this state and mainly protein and lipid-restricted diets from among these. Some lean and fat body mass indices predictive of malnutrition are proposed taking into account the influence of liver disease in their evaluation. Nitrogen balance derangements and liposoluble vitamins and carotenoids plasma decrease are highlighted as sensitive nutritional parameters. After a brief review of amino acid, glucose and lipid metabolic derangements, some nutritional guidelines are provided by distinguishing oral selective supports from the parenteral nutrition. The latter, being reserved to moderate-severe encephalopathy or to hemorrhagic conditions, is proposed following an algorithm which takes into account different nutritional principles as a function of the severity of the clinical condition. During the first period (24-48 hrs) parenteral fluids, electrolytes, dextrose and whole blood or derivatives (when necessary) are provided; lactulose or lactitol via nasogastric tube, or by enema, are started as well. During the following 48-72 hrs branched-chain amino acids alone or enriched solutions are added taking into account an optimum calorie/nitrogen ratio. Finally, vegetable lipids, vitamins and oligoelements can be added if intravenous nutrition must be maintained, with a view of warranting the most complete nutritional approach to these severely malnourished patients.