1. Does low protein diet really beneficial for
hepatic disease patient?
Role of low protein intake in the management of
Hepatic Encephalopathy and Cirrhosis
By: Chun-Yeung Li, Dietetic Intern
Proctorship: Memorial Hospital Pembroke Dietetic Team
September 2016 – November 2016

2. Introduction
 Malnutrition and hepatic encephalopathy (HE) are two of the
most common complications of cirrhosis and both have
detrimental effects on outcome. 1
 The restriction of dietary protein intake in patients with cirrhosis
and hepatic encephalopathy became common practice between
1970s- 1980s but it was never clearly evidence-based proven.2
 Restriction of dietary oral protein in cirrhotic patients with or
without HE was an accepted standard of care for many decades.
 Despite the advice of experts in the nutrition field, some
physicians and dietitian believe that protein restriction is needed
in pt with HE and cirrhosis.3,4

3. Cirrhosis
 From the American Liver Foundation, Cirrhosis refers to the
replacement of normal liver tissue with non-living scar tissue.
It is always related to other liver diseases.
 Cirrhosis is the scarring of the liver - hard scar tissue replaces
soft healthy tissue.
 As cirrhosis becomes worse, the liver will have less healthy
tissue.
 Cirrhosis is caused by chronic (long-term) liver diseases that
damage liver tissue. It can take many years for liver damage
to lead to cirrhosis. Such as Chronic Alcoholism, Chronic Viral
Hepatitis, and Nonalcoholic steatohepatitis (NASH).

4. Hepatic Encephalopathy (HE)
 A major neuropsychiatric complication of end-stage liver failure.
 A spectrum of neuropsychiatric abnormalities in patients with
liver disease, after exclusion of other known brain diseases.
Picture Reference: http://www.qwhatis.com/what-is-hepatic-encephalopathy/

5. “Let Them Eat!”
 “Normal protein diet for episodic hepatic encephalopathy: results
of a randomized study” by Juan Co´rdoba and his team
concluded a normal protein diet was safe and did not exacerbate
HE. 5
 Co´rdoba and colleague also suggestive there are disadvantage
to restricting protein in HE.
 However, only less that 36% of the dietitian from a study
recommended an adequate protein intake for patients with
hepatic encephalopathy. 4
 Limiting protein and calories will eventually lead to Protein
calories malnutrition (PCM).

6. Liver Diseases V.S. Protein Inake
 Ammonia has multiple neurotoxic effects
and is currently the prevailing theoretical
cause of HE.
 A healthy liver clears almost all of the
portal vein ammonia, converting it into
urea or glutamine for excretion.
 However, patients with cirrhosis and HE
commonly already have macronutrient
and micronutrient deficiencies.
 There is an overall loss of protein from
reduced synthesis of urea and hepatic
proteins, reduced intestinal protein
absorption, and increased urinary
nitrogen excretion.

7. What is the Dietary Guideline?
 According to the Nutrition Care Manual, it did not specify a
low protein diet nor addition protein to a regular diet for
the cirrhosis patients.
 It stated the amount of protein you should eat will depends on
your symptoms.
 It suggested patients to avoid food that are high in sodium,
such as canned soups, many canned vegetables and
processed meats.

8. What is the Dietary Guideline?
 The author of “Role of Nutrition in the Management of Hepatic Encephalopathy
in End-Stage Liver Failure” suggested the following guideline for End-stage
liver failure patients. 6 (Table 2)
 Small meals evenly distributed throughout the day and a late-night snack of
complex carbohydrate will help minimize protein utilization. 7

9. Food Source Matters?
 It has suggested vegetable proteins are better tolerated than animal protein in
pts, finding that has been attributed to either their higher content of branched-
chain amino acid and/or because of their influence on intestinal transit. 6
 One study reported that a diet rich in vegetable protein (~71g/d) significantly
improved the mental status of patients suffering from HE while increasing their
nitrogen balance. 8
 Fiber has prebiotic properties that result in decreased transit time, reduced
intraluminal pH, and increased fecal ammonia excretion. 7

10. Translating findings in to reality
 In one study, the protein reduction regimen did not cause any
major benefit of HE, whereas the low-protein diet exacerbated
protein breakdown. 3
 It further support the hypothesis that long-term protein restriction
may worsen the patient’s nutrition status.
 Low protein diets should be avoided and protein intake
maintained at 1.2-1.5g/kg/day.
 Particularly vegetable protein and BCAAs (Leucine, Isoleucine
and Valine) which have proven beneficial in the treatment of
HE.7,9

11. Limitation
Small Sample Size
- Some of the research only conducted with less than a 100 participants.
Short Duration of the protein restriction
- Inhumane for experiment
Current Technology
- Does not allow for the accurate assessment of body composition/ a
more precise description of the specific components that constitute malnutrition in a
given individual.
Standardized Evaluation
- A standardized simple and accurate method for evaluating malnutrition in
end-stage liver failure remains a challenge.

12. Questions?

13. References
1. D'Amico G, Garcia-Tsao G,Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a
systematic review of 118 studies. J Hepatol 2006;44: 217–231.
2. Donaghy A. Issues of malnutrition and bone disease in patients with cirrhosis. J Gastroenterol Hepatol 2002; 17:
462-466
3. Cabral, Chad Michael, and David L. Burns. "Low-Protein Diets for Hepatic Encephalopathy Debunked: Let them
Eat Steak." Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral
Nutrition 26.2 (2011): 155.
4. Joanne K Heyman, Carol J Whitfield, et al. Dietary protein intakes in patients with hepatic encephalopathy and
cirrhosis: current practice in NSW and ACT. August 2006; 185(10): 542-543
5. Córdoba J, López-Hellín J, Guardia J, et al. Normal protein diet for episodic hepatic encephalopathy: results of a
randomized study.Journal Of Hepatology [serial online]. July 2004;41(1):38-43. Available from: Academic Search
Complete, Ipswich, MA. Accessed October 10, 2016.
6. Bémeur C, Desjardins P, Butterworth R. Role of Nutrition in the Management of Hepatic Encephalopathy in End-
Stage Liver Failure. Journal Of Nutrition & Metabolism [serial online]. January 2010;:1-12. Available from:
Academic Search Complete, Ipswich, MA. Accessed October 11, 2016.
7. Amodio, Piero, et al. "The Nutritional Management of Hepatic Encephalopathy in Patients with Cirrhosis:
International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus." Hepatology 58.1 (2013):
325-36. Print.
8. G. P. Bianchi, G. Marchesini, A. Fabbri et al., “Vegetable versus animal protein diet in cirrhotic patients with
chronic encephalopathy. A randomized cross-over comparison,” Journal of Internal Medicine, vol. 233, no. 5, pp.
385–392, 1993.
9. Bémeur C, Desjardins P, Butterworth R. Role of Nutrition in the Management of Hepatic Encephalopathy in End-
Stage Liver Failure. Journal Of Nutrition & Metabolism [serial online]. January 2010;:1-12. Available from:
Academic Search Complete, Ipswich, MA. Accessed October 21, 2016.