Nutritional Management of Hepatic Encephalopathy Presented by Chris

Nutritional Management of Hepatic Encephalopathy Presented by Chris Theberge & Sara Murkowski

Presentation At A Glance n Background on Liver Dysfunction ¨ Review of liver physiology ¨ Diseases of the liver n Development of Hepatic Encephalopathy ¨ Pathogenesis Theories ¨ Incidence, Prognosis, Diagnostic Criteria ¨ Clinical manifestations, Nutritional manifestations ¨ Treatment: Medical Management n n Case Study Nutritional Management ¨ Historical Treatment Theories/Practice n Protein Restriction & BCAA Supplementation ¨ Goals of MNT

Let’s Take It From The Top n A Physiology Review

Functions of the Liver: A Brief Overview n n n Largest organ in body, integral to most metabolic functions of body, performing over 500 tasks Only 10 -20% of functioning liver is required to sustain life Removal of liver will result in death within 24 hours

Functions of the Liver n Main functions include: ¨ Metabolism of CHO, protein, fat ¨ Storage/activation vitamins and minerals ¨ Formation/excretion of bile ¨ Steroid metabolism, detoxifier of drugs/alcohol ¨ Action as (bacteria) filter and fluid chamber ¨ Conversion n n of ammonia to urea Gastrointestinal tract significant source of ammonia Generated from ingested protein substances that are deaminated by colonic bacteria Ammonia enters circulation via portal vein Converted to urea by liver for excretion

The Urea Cycle Aspartate Transaminase(AST) Alanine Transaminase (ALT)

Liver Diseases Classifications n n Duration ¨ Acute vs Chronic Pathophysiology ¨ Hepatocellular vs Cholestasic Etiology ¨ Viral ¨ Alcohol ¨ Toxin ¨ Autoimmune Stage/Severity ¨ ESLD ¨ Cirrhosis w. Viral hepatitis A, B, C, D, E (and G) w. Fulminant hepatitis w. Alcoholic liver disease w. Non-alcoholic liver disease w. Cholestatic liver disease w. Hepatocellular carcinoma w. Inherited disorders

Liver Diseases n Fulminant Hepatic Failure (“Shocked Liver”) ¨ Rapid, severe acute liver injury with impaired function and encephalopathy in someone with a previously normal liver or with well-compensated liver disease n n Encephalopathy within 8 weeks of symptom onset or within 2 wks of developing jaundice Multiple causes (ie, drug toxicity, hepatitis) Malnutrition often not major issue Chronic Hepatic Failure (“Subfulminant" Hepatic Failure) ¨ At least 6 -month course of hepatitis or biochemical and clinical evidence of liver disease with confirmatory biopsy findings of unresolving hepatic inflammation ¨ Multiple causes: autoimmune, viral, metabolic, toxic

Liver Diseases Cholestatic Liver Diseases n Primary biliary cirrhosis (PBC) Immune-mediated chronic cirrhosis of the liver due to obstruction or infection of the small and intermediate-sized intrahepatic bile ducts ¨ 90% of patients are women ¨ Nutritional complications ¨ n n Osteopenia, hypercholesterolemia, fat-soluble vitamin deficiencies Sclerosing cholangitis Fibrosing inflammation of segments of extrahepatic bile ducts, with or without involvement of intrahepatic ducts ¨ Nutritional complications ¨ n Inflammatory bowel disease, fat soluble vitamin deficiencies, hepatic osteodystrophy (steatorrhea)

Inherited Liver Disorders n Hemochromatosis ¨ Inherited disease of iron overload n Wilson’s disease ¨ Autosomal recessive disorder associated with impaired biliary copper excretion n α 1 -antitrypsin deficiency ¨ Causes cholestasis or cirrhosis and can cause liver and lung cancer

Liver Diseases n Alcoholic Liver Disease, Alcoholic hepatitis, and Cirrhosis ¨ Diseases resulting from excessive alcohol ingestion characterized by fatty liver (hepatic steatosis), hepatitis, or cirrhosis (fibrous tissue) ¨ Prognosis depends on degree of abstinence and degree of complications ¨ Malnutrition often an issue in these patients ¨ Most common liver disease in US

Progression of Liver Diseases

Normal Liver

Alcoholic Fatty Liver

Cirrhotic Liver

Prognosis of Cirrhosis Child-Pugh and MELD Score Both used to determine prognosis of Cirrhosis (mortality and survival) Determine Need For Transplantation Used in studies to determine effect of treatment on liver function

Malnutrition In Liver Disease n Malnutrition is an early and typical aspect of hepatic cirrhosis ¨ n Contributes to poor prognosis and complications Degree of malnutrition related to severity of liver dysfunction and disease etiology (higher in alcoholics) Mortality doubled in cirrhotic patients with malnutrition (35% vs 16%) ¨ Complications more frequent than in well-nourished (44% vs 24%) ¨ Usually more of a clinical problem than hepatic encephalopathy itself ¨

Cirrhosis is common end result of many chronic liver disorders n Severe damage to structure & function of normal cells n Inhibits normal blood flow n Decrease in # functional hepatocytes n Results in portal hypertension & ascites n Portal systemic shunting ¨Blood bypasses the liver via shunt, thus bypassing detoxification ¨Toxins remain in circulating blood ¨Neurtoxic substances can precipitate hepatic encephalopathy

And Now Our Featured Presentation…

What is Hepatic Encephalopathy? n Broadly defined ¨ n n n All neurological and psychological symptoms in patients with liver disease that cannot be explained by presence of other pathologies Brain and nervous system damage secondary to severe liver dysfunction (most often chronic disease) resulting from failure of liver to remove toxins Multifactorial pathogenesis with exact cause unknown Symptoms vary from nearly undetectable, to coma with decerebration ¨ Characterized by various neurologic symptoms n n Cognitive impairment Neuromuscular disturbance Altered consciousness Reversible syndrome

Incidence & Prognosis n Incidence ¨ 10 -50% of cirrhotic pts and portal-systemic shunts (TIPS) experience episode of overt hepatic encephalopathy ¨ True incidence/prevalence of HE unknown n Lack of definitive diagnosis Wide spectrum of disease severity Prognosis ¨ 40% survival rate 1 year following first episode ¨ 15% survival rate 3 years following first episode

Clinical Manifestations of HE n n n Cerebral edema Brain herniation Progressive, irreversible coma Permanent neurologic losses (movement, sensation, or mental state) Increased risk of: ¨ Sepsis ¨ Respiratory failure ¨ Cardiovascular collapse ¨ Kidney Failure

Variants of Hepatic Encephalopathy n Acute HE ¨ Associated with marked cerebral edema seen in patients with the acute onset of hepatic failure (FHF) n Hormonal disarray, hypokalemia, vasodilation (ie, vasopressin release) ¨ Quick progression: coma, seizures, and decerebrate rigidity ¨ Altered mental function attributed to increased permeability of the blood-brain barrier and impaired brain osmoregulation n Results in brain cell swelling and brain edema ¨ Can occur in cirrhosis, but usually triggered by precipitating factor ¨ Precipitating factors usually determine outcome

Precipitants of Hepatic Encephalopathy Drugs • Benzodiazepines • Narcotics • Alcohol Dehydration • Vomiting • Diarrhea • Hemorrhage • Diuretics • Large volume paracentesis Primary Hepatocellular Carcinoma Portosystemic Shunting • Radiographic or surgically placed shunts • Spontaneous shunts • Vascular Occlusion • Portal or Hepatic Vein Thrombosis Increased Ammonia Production, Absorption or Entry Into the Brain • Excess Dietary Intake of Protein • GI Bleeding • Infection • Electrolyte Disturbances (ie. , hypokalemia) • Constipation • Metabolic alkalosis

Variants of Hepatic Encephalopathy n Chronic HE Occurs in subjects with chronic liver disease such as cirrhosis and portosystemic shunting of blood (Portal Systemic Encepalopathy [PSA]) ¨ Characterized by persistence of neuropsychiatric symptoms despite adequate medical therapy. ¨ Brain edema is rarely reported ¨ n Refractory HE ¨ Recurrent episodes of an altered mental state in absence of precipitating factors Persistent HE ¨ Progressive, irreversible neurologic findings: dementia, extrapyramidal manifestations, cerebellar degeneration, transverse cordal myelopathy, and peripheral neuropathy n Subclinical or “Minimal HE” n Most frequent neurological disturbance ¨ Not associated with overt neuropsychiatric symptoms ¨ Subtle changes detected by special psychomotor tests ¨

Stages of Hepatic Encephalophay Stage Symptoms Mild Confusion, agitation, irritability, I sleep disturbance, decreased attention II Lethargy, disorientation, inappropriate behavior, drowsiness III Somnolent but arousable, slurred speech, confused, aggressive IV Coma

Pathogenesis Theories n Endogenous Neurotoxins ¨ Ammonia ¨ Mercaptans ¨ Phenols ¨ Short-medium fatty acids n n Increased Permeability of Blood-Brain Barrier Change in Neurotransmitters and Receptors ¨ GABA ¨ Altered BCAA/AAA ratio n Other ¨ Zinc defficiency ¨ Manganese deposits

Neurotoxic Action of Ammonia n n Readily crosses blood-brain barrier Increased NH 3 = increased glutamate α-ketoglutarate+NH 3+NADH→glutamate+NAD ¨ glutamate+NH 3+ATP→glutamine+ADP+Pi ¨ n n As a-ketoglutarate is depleted TCA cycle activity halted Increased glutamine formation depletes glutamate stores which are needed by neural tissue ¨ Irrepairable cell damage and neural cell death ensue. ¨ In liver disease, conversion of ammonia to urea and glutamine can be reduced up to 80%

Pathogenesis Theories: False Neurotransmitter Hypothesis n Liver cirrhosis characterized by altered amino acid metabolism Increased Aromatic Amino Acids in plasma and influx in brain n Decrease in plasma Branched Chain Amino Acids n Share a common carrier at blood-brain barrier n BCAAs in blood may result in AAA transport to brain n

Abnormal plasma amino acids: chronic liver disease 400 Glu % of Normal 350 Phe Asp Meth 300 250 Tyr 200 Try 150 100 Thr Val. Leu 50 Gly Lys Tau Orn Ser Pro His Ala Arg Ileu Essential Cerra, et al; JPEN, 1985 Non-Essential J. Y. Pang

Pathogenesis Theories: False Neurotransmitter Hypothesis n AAA are precursors to neurotransmitters and elevated levels result in shunting to secondary pathways

Pathogenesis Theories: Change In Neurotransmitters and Receptors n Gamma-Aminobutyric Acid (GABA) n BCAA-Ammonia Connection

Increase Permeability of Blood. Brain Barrier n n Astrocyte (glial cell) volume is controlled by intracellular organic osmolyte Organic osmolyte is glutamine levels in the brain result in volume of fluid within astrocytes resulting in cerebral edema (enlarged glial cells) Neurological impairment ¨ N=Normal Astrocytes ¨ A=Alzheimer type II astrocytes ¨ Pale, enlarged nuclei ¨ characterisic of HE

Symptoms of HE n Changes in mental state, consciousness ¨ Confusion, disorientation ¨ Delirium ¨ Dementia (loss of memory, intellect) ¨ Mood swings ¨ Decreased altertness, responsiveness ¨ Coma n n n Course muscle tremors Muscle stiffness or rigidity Loss of small hand movements (handwriting) Seizures (rare) Decreased self-care ability Speech impairment

Diagnosing HE n No single laboratory test is sufficient to establish the diagnosis ¨ No n Gold Standard Pt brains cannot be studied with neurochemical/neurophysiologic methods ¨ Data on cerebral function in HE usually derived from animal studies n Underlying cause of liver disease itself may be associated with neurologic manifestations ¨ Alcoholic liver disease (Wernicke’s)

Diagnostic Criteria n n n Asterixis (“flapping tremor”) Hx liver disease Impaired performance on neuropsychological tests ¨ n n Sleep disturbances Fetor Hepaticus Slowing of brain waves on EEG PET scan ¨ n Visual, sensory, brainstem auditory evoked potentials Changes of neurotransmission, astrocyte function Elevated serum NH 3 Stored blood contains ~30 ug/L ammonia ¨ Elevated levels seen in 90% pts with HE ¨ Not needed for diagnosis ¨

Table 3. Differential diagnostic considerations in hepatic encephalopathy Differential Diagnosis Metabolic encephalopathies Diabetes (hypoglycemia, ketoacidosis) Hypoxia Carbon dioxide narcosis Toxic encephalopathies Alcohol (acute alcohol intoxication, delirium tremens, Wernicke. Korsakoff syndrome) Drugs Intracranial events Intracerebral bleeding or infarction Tumor Infections (abscess, meningitis) Encephalitis

Treatment of Hepatic Encephalopathy n Various measures in current treatment of HE ¨ Strategies to lower ammonia production/absorption n Nutritional management ¨ ¨ n Protein restriction BCAA supplementation Medical management ¨ Medications to counteract ammonia’s effect on brain cell function n n Lactulose Antibiotics ¨ Devices to compensate for liver dysfunction ¨ Liver transplantation

Proposed Complex Feedback Mechanisms In Treatment Of HE

Nutritional Management of HE n Historical treatment theories ¨ Protein Restriction ¨ BCAA supplementation n Goals of MNT ¨ Treatment of PCM associated with ESLD

Historical Treatment Theories: Protein Restriction n n Studies in early 1950’s showed cirrhotic pts given “nitrogenous substances” developed hepatic “precoma” Led to introduction of protein restriction ¨ Began with 20 -40 g protein/day ¨ Increased by 10 g increments q 3 -5 days as tolerated with clinical recovery ¨ Upper limit of 0. 8 -1. 0 g/kg ¨ Was thought sufficient to achieve positive nitrogen balance n Lack of Valid Evidence ¨ Efficacy of restriction never proven within controlled trial

Dispelling the Myth Normal Protein Diet for Episodic Hepatic Encephalopathy Cordoba et al. J Hepatol 2004; 41: 38 -43 n n Objective: To test safety of normal-protein diets Randomized, controlled trial in 20 cirrhotic patients with HE ¨ 10 patients subjected to protein restriction, followed by progressive increments n No protein first 3 days, increasing q 3 days until 1. 2 g/kg daily for last 2 days ¨ 10 patients followed normal protein diet (1. 2 g/kg) ¨ Both groups received equal calories

Dispelling the Myth n Results ¨ On days 2 and 14: Similar protein synthesis among both groups n Protein breakdown higher in low-protein group n n Conclusion ¨ No significant differences in course of hepatic encephalopathy ¨ Greater protein breakdown in proteinrestricted subjects

Protein and HE Considerations n n Presence of malnutrition in pts with cirrhosis and ESLD clearly established No valid clinical evidence supporting protein restriction in pts with acute HE Higher protein intake required in CHE to maintain positive nitrogen balance Protein intake < 40 g/day contributes to malnutrition and worsening HE ¨ Increased endogenous protein breakdown NH 3 n Susceptibiliy to infection increases under such catabolic conditions

Other Considerations n Vegetable Protein ¨ Beneficial in patients with protein intolerance <1 g/kg n Considered to improve nitrogen balance without worsening HE ¨ Beneficial effect d/t high fiber content n Also elevated calorie-to-nitrogen ratio n BCAA Supplementation ¨ Effective or Not?

Branched Chain Amino Acids (BCAA) Valine Leucine Isoleucine • Important fuel sources for skeletal muscle during periods of metabolic stress • Metabolized in muscle & brain, not liver -promote protein synthesis -suppress protein catabolism -substrates for gluconeogenesis Catabolized to L-alanine and L-glutamine in skeletal muscle

Nutritional Supplementation with Branched. Chain Amino Acids in Advanced Cirrhosis: A Double-Blind, Randomized Trial Marchesini et al. , (2004). Gastroenterology, 124, 1792 -1801

Nutritional Supplementation with Branched-Chain Amino Acids in Advanced Cirrhosis: A Double-Blind, Randomized Trial n n Multi-Center, randomized, controlled study involving 15 centers with interest in patients with liver disease Inclusion Criteria A diagnosis of liver cirrhosis documented by histology and confirmed lab data ¨ Child-Pugh score ≥ 7 (Class B or C) ¨ Sonographic and endoscopic evidence of portal hypertension ¨ n Exclusion Criteria ¨ Active alcohol consumption, overt HE, refractory ascites, reduced renal function (Cre ≥ 1. 5 mg/d. L), Child-Pugh score ≥ 12, suspected hepatocellular carcinoma, previous poor compliance to pharmacological treatment of nutrition counseling

Nutritional Supplementation with Branched-Chain Amino Acids in Advanced Cirrhosis: A Double-Blind, Randomized Trial n Primary Outcomes ¨ Combined survival and maintenance of liver function, as assessed by death (any reason), deterioration to exclusion criteria, or transplant ¨ Number of hospital admissions ¨ Duration of hospital stay n Secondary Outcomes ¨ Nutritional parameters and liver function tests (Child- Pugh scores) ¨ Anorexia and health-related quality of life ¨ Therapy needs

BCAA Lactoalbu min Maltodextrin Total number 59 56 59 Lost to follow-up 1 — — Intention-to-treat analysis 58 56 59 9 (15. 5%)* 18 (32. 1%) 16 (27. 1%) Removed from systematic follow-up 1 7 4 4 Development of HCC 2 1 1 2 Noncompliance to treatment 3 5 (1) 2 (1) 0 Side effects 3 44 (1) 2 — 1 — Regular 3 -mo follow-up 42 (71. 2%)* 34 (60. 7%) 39 (66. 1%) Admission to hospital 15 (35. 7%)* 27 (79. 4%) 28 (71. 8) 0. 6 ± 0. 2* 2. 1 ± 0. 5 1. 9 ± 0. 4 Study Profile of BCAA Trial Events (death, any cause, or progression of liver failure to exclusion criteria) Treatment-unrelated diseases Admission rate (patients/y) Total no. d in hospital 195* 327 520 * Significantly different from both lactoalbumin and maltodextrin. 1 Some individuals were removed based on more than 1 criterion. 2 Cases with HCC were censored at the time of HCC diagnosis. 3 The number of withdrawn patients who died or progressed to exclusion criteria within 12 mo from entry into the study is reported in parentheses. 4 Including the patient lost to follow-up.

Primary Outcome Results n Based on ITT, time course of events was not different between groups (p=0. 101) ¨ A benefit of BCAA only found when nonliver disease-related events excluded from analyses compared to L-ALB n BCAA significantly reduced the combined event rates compared with L-ALB, but not with M-DXT ¨L-ALB-OR, 0. 43; 95% CI (0. 19 -0. 96); p=0. 039 ¨M-DXT-OR, 0. 51; 95% CI (0. 23 -1. 17); p=0. 108 n Less frequent hospital admissions with BCAA vs two control arms (p = 0. 021)

Secondary Outcomes Nutritional Parameters • No change in serum albumin among groups • Significant interaction between BCAA and M-DXT • Significant reduction in prevalence and severity of ascites in BCAA vs controls • No significant improvement in HE based on Reitan Test) • Trend for superiority of BCAA over M-DXT (p=0. 108)

Anorexia and Health-Related Quality of Life n Increased hunger/satiety in BCAA (p=0. 019), while no change in L-ALB and M-DXT (p=0. 026) n Prevalence of anorexia significantly (p=0. 0014) decreased in BCAA, while unchanged in controls n Significant improvement in physical functioning in BCAA, while no change in controls n Trend (p=0. 069) towards better scoring of health in subjects with BCAA only n After 1 year, the percentage of subjects who felt their health improved increased (29% to 52%) and who felt it had worsened decreased (43% to 18%) (p=0. 001)

Conclusions n Long-term BCAA supplementation showed an advantage compared to equicaloric, equinitrogenous supplemenation ¨ Prevention of combined death ¨ Progressive liver failure ¨ Hospital rates ¨ Secondary Outcomes

The Mother of All BCAA Trials? Randomized Study Limitations n Poor subject compliance and adverse reactions 3 times more common in BCAA (15%) arm compared to controls (5% combined) resulting in greater withdrawal ¨ n Only 115 of 174 subjects had regular f/u at end of study, reducing power ¨ n May explain lack no difference in time course of events A benefit of BCAA supplementation only found when non -liver-related deaths were excluded from analysis ¨ n Ascertainment bias for event rates Mortality was lower, but BCAA group had similar number of deaths compared to the other groups Mean admission rate lower in BCAA compared to controls ¨ ¨ No cost-effectiveness analysis done Reasons for hospital admission?

The Mother of All BCAA Trials? Further Study Limitations n No differences in encephalopathy test scores, including Reitan testing seen among treatment groups, but significant improvement in nutritional status in BCAA compared to others ¨ Most likely this attributed to reduced admission rates

Branched-Chain Amino Acids For Hepatic Encephalopathy Als-Nielsen B, Koretz RI, Kjaergard LL, Gluud C. The Cochrane Database of Systematic Reviews, 2003, 1 -55

Branched-Chain Amino Acids For Hepatic Encephalopathy n Meta-Analysis of randomized-controlled trials on the treatment of HE with IV or oral BCAA n Objective ¨ n To evaluate the beneficial and harmful effects of BCAA or BCAAenriched interventions for patients with hepatic encepalopathy Review Criteria All randomized trials included, irrespective of blinding, publication status, or language ¨ Data from first period of crossover trials and unpublished trials included if methodology and data accessible ¨ Excluded trials in which patients allocated by quasi-random method ¨ n Participants Patients with HE in connection with acute or chronic liver disease or FHF ¨ Patients of either gender, any age and ethnicity included irrespective of etiology of liver disease or precipitating factors of HE ¨

Branched-Chain Amino Acids For Hepatic Encephalopathy n Types of Interventions ¨ Experimental Group n ¨ Control Group n n BCAA or BCAA-enriched solutions given in any mode, dose, or duration with or without other nutritive sources No nutritional support, placebo support, isocaloric support, isonitrogenous support, or other interventions with a potential effect on HE (ie. , lactulose) Outcome Measures ¨ Primary n ¨ Improvement of HE (number of patients improving from HE using definitions of individual trials) Secondary n n n Time to improvement of HE (number of hours/days with HE from the time of randomization to improvement) Survival (number of patients surviving at end of treatment and at max f/up according to trial) Adverse events (number and types of events defined as any untoward medical occurrence in a patient, not necessarily causal with treatment)

Branched-Chain Amino Acids For Hepatic Encephalopathy n Data Collection and Analysis Trial inclusion and data extraction made independently by two reviewers ¨ Statistical heterogeneity tested using random effects and fixed effect models ¨ Binary outcomes reported as risk ratios (RR) based on random effects model ¨

Branched-Chain Amino Acids For Hepatic Encephalopathy: Results n Eleven randomized trials (556 patients) Trial types: BCAA versus carbohydrates, neomycin/lactulose, or isonitrogenous controls ¨ Median number of patients in each trial: 55 (range 22 to 75) ¨ Follow-up after treatment reported in 4 trials ¨ n ¨ Compared to control regimens, BCAA significantly increased the number of patients improving from HE at end of treatment n ¨ Median 17 days (range 6 to 30 days) RR 1. 31, 95% CI 1. 04 to 1. 66, 9 trials No evidence of an effect of BCAA on survival n n RR 1. 06, 95% CI 0. 98 to 1. 14, 8 trials No adverse events (RR 0. 97, 95% CI 0. 41 to 2. 31, 3 trials)

Significant

Not significant Combining survival data regardless of window of f/u showed no significant Difference in survival between BCAA and controls

Branched-Chain Amino Acids For Hepatic Encephalopathy: Results n Sensitivity Analyses ¨ Methodological quality had a significant impact on results n Higher quality vs lower quality In trials with adequate generation of allocation sequence, allocation concealment, and adequate double-blinding, BCAA had no significant effect on improvement or survival ¨ In trials with unclear generation of allocation sequence, allocation concealment, and inadequate double-blinding a significant effect of BCAA on HE was found ¨ BCAA had no significant effect on survival when given parenterally to acute HE or enterally to chronic HE ¨ n ¨ Discrepancy between each applied model (fixed vs random) Trend towards beneficial effect of BCAA using best-case analysis with fixed model only [p=0. 03 vs p=0. 13 with random] n No significant effect of BCAA with worst-case analysis

Conclusions n No convincing evidence that BCAA had a significant beneficial effect on improvement of HE or survival in patients with HE ¨ n Primary analysis showed a significant benefit of BCAA on HE, but significant statistical heterogeneity was present and result not robust to sensitivity analysis ¨ n Low methodological quality source of heterogeneity (=bias) Benefits of BCAA on HE only observed when lower quality studies included ¨ n Small trials with short f/u and most of poor quality Effect size and “small study bias” No significant association between dose or duration and the effect of BCAA

Conclusions n In general, BCAAs were more effective when given enterally to subjects with chronic encephalopathy, then when given IV to patients with acute encephalopathy ¨ Most likely through improved nutrition

Limitations n n Significant heterogeneity among studies (ie. , patient populations, settings, routine care) making a meta-analysis decipherable Division of HE into categories is arbitrary and precipitating factors not always identified The definition of “improvement” different among studies Scales and items used for defining and assessing HE are arbitrary and not tested for reliability or validity

Implications For Future Research n n The absence of evidence for an effect of BCAA does not mean there is evidence of lack of effect Future randomized trials warranted Trials could randomize according various types of HE to BCAA versus placebo All trials should use parallel group design ¨ ¨ n Spontaneously fluctuating nature of HE Need for assessing outcomes (improvement, recovery, mortality, and adverse events) after end of treatment There is substantial need for clear diagnostic criteria of HE, as well as reassessment and validation of scales and items used for measuring its course

Implications For Future Research n n n New studies are awaited to identify patients at higher risk where BCAA is probably the only way to prevent catabolic losses and improve prognosis Dose-finding studies are needed to detect optimum dosage, safe limits of administration, and whether higher doses will show more benefit Studies needed to define whether all 3 BCAA’s need to be supplied ¨ ¨ Effects of leucine on protein turnover and HGF secretion Leucine alone might achieve similar beneficial results at lower total doses

BCAA Enteral Formulations n Nutri. Hep Enteral Nutrition (Nestle) n Hepatic-Aid II (Hormel Health Labs) ¨ 1. 5 kcal/m. L ¨ 1. 2 kcal/m. L ¨ Fat (12%) MCT ¨ Fat (28%) No MCT (66%) ¨ Protein: 50% BCAA, low MET ¨ CHO: 77% ¨ RDI: 100% ¨ Gluten-free, lactose-free ¨ Protein: 46% BCAA, low AAA ¨ CHO: 58% ¨ Vitamin and Electrolyte-free

The Child-Turcotte-Pugh Classification

Goals of MNT for HE n Treatment of PCM associated with Underlying Liver Disease ¨ Suppression of endogenous protein breakdown to reduce stress placed on de-compensated liver ¨ Achieve positive nitrogen balance without exacerbating neurological symptoms n n PCM associated with morbidity and mortality in cirrhosis (6590% with PCM) Severity of pcm positively correlated with mortality

Nutritional Implications: PCM associated Liver Dz n n Malnutrition reported in 65%-90% cirrhotic pts Poor Dietary Intake ¨ ¨ ¨ Anorexia Dietary Restrictions Ascites Gastroparesis Zinc Deficiency Increased proinflammatory cytokines n Nutrient malabsorption/ maldigestion Cholestatic & non-cholestatic liver disease ¨ Excessive protein losses ¨ Pancreatic insufficiency ¨ n Abnormal Metabolism ¨ ¨ ¨ Hypermetabolism Hyperglucogonemia Increased protein metabolism Increased lipid oxidation Osteopenia

MNT in Advanced Liver Disease n Poor Dietary Intake ¨ Due to poor appetite, early satiety with ascites n Small frequent meals n Aggressive oral supplementation n Zinc supplementation n Nutrient Malabsorption ¨ Due to bile, failure to convert to active forms n ADEK supplementation n Calcium + D supplementation n Folic Acid Supplementation

MNT in Advanced Liver Disease n Abnormal Fuel Metabolism ¨ Increased perioxidation, gluconeogenesis n n Bedtime meal to decrease Protein Deficiency ¨ protein catabolism, repeat paracentesis High protein snacks/supplements n 1. 2 -1. 5 gms/day n

MNT in Advanced Liver Disease n Standard Guidelines ¨ MVI with minerals ¨ 2 gm Na restriction in presence of ascites ¨ Do not restrict fluid unless serum Na <120 mmol ¨ Low threshold for NGT in pts awaiting transplant ¨ TPN should be considered only if contraindication for enteral feeding

How Much Protein: That is the Question n Grade III to IV hepatic encephalopathy ¨ Usually no oral nutrition ¨ Upon improvement, individual protein tolerance can be titrated by gradually increasing oral protein intake every three to five days from a baseline of 40 g/day ¨ Oral protein not to exceed 70 g/day if pt has hx if hepatic encephalopathy ¨ Below 70 g/day rarely necessary, minimum intake should not be lower than 40 g/day to avoid negative nitrogen balance

MNT Specifically in HE n n Non-protein energy: 35 -45 kcal/kg/day Up to 1. 6 g/kg/day protein as tolerated ¨ Low-grade HE (minimal, I, II) should not be contraindication to adequate protein supply n 40 g temporary restriction if considered protein intolerant, but gradual increase q 3 -5 days ¨ 30 -40 g Vegetable protein/day for these pts n In patients intolerant of a daily intake of 1 g protein/kg, oral BCAA up to 0. 25 g/kg may be beneficial to create best possible nitrogen balance ¨ BCAA’s do not exacerbate encephalopathy

MNT Specifically in HE coma (grade III-IV) ¨ Usually no oral nutrition ¨ Upon improvement, individual protein tolerance can be titrated by gradually increasing oral protein intake every three to five days from a baseline of 40 g/day ¨ Enteral and parenteral regimens providing 25 -30 kcal/kg/day non-protein energy ¨ 1. 0 g/kg/day protein, depending on degree of muscle wasting ¨ BCAA-enriched solutions may benefit protein intolerant (<1 g/kg)

Conclusions in HE Management n n Intervention directed against the precipitating cause(s) will lead to improvement or disappearance of acute hepatic encephalopathy Our understanding of pathogenesis is improving, but much work remains Link between liver and brain still only partially understood No evidence supporting standard use of BCAA formulations, but may benefit small subgroup ¨ Cost analysis not conducted in trials n Cost outweigh benefits for standard protocol

Thank You! n Special Thanks to Nicole Varady Comments? n Questions? n

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