Nutritional Management of Patients with Cirrhosis and Hepatic Encephalopathy

Guideline Watch |
July 19, 2013

Nutritional Management of Patients with Cirrhosis and Hepatic Encephalopathy

  1. Atif Zaman, MD, MPHAU967

Consensus recommendations are now available despite continued knowledge gaps in this area.

  1. Atif Zaman, MD, MPHAU967

An expert panel commissioned by the International Society for Hepatic Encephalopathy and Nitrogen Metabolism has recommended that all patients with cirrhosis and hepatic encephalopathy should receive nutritional management similar to that for patients with cirrhosis but without hepatic encephalopathy. Specific recommendations from their consensus document are described below.

Strongest recommendations:

  • All patients should undergo baseline nutritional assessment as a part of management. (The authors acknowledged that no clinically practical, well-validated tools to assess nutrition are currently available.)

  • Optimal daily energy intake should be 35 to 40 kcal/kg ideal body weight.

  • Optimal daily protein intake should be 1.2 to 1.5 g/kg ideal body weight.

  • Small meals evenly distributed throughout the day and a late-night snack of complex carbohydrate are ideal.

  • Hyponatremia should always be corrected slowly.

Recommendations with less certainty, but with moderate evidence:

  • Encourage a diet rich in vegetable and daily protein.

  • Branched-chain amino acid supplementation might allow recommended nitrogen intake to be maintained in patients intolerant of dietary protein.

  • A 2-week course of a multivitamin could be justified in patients with decompensated cirrhosis.

  • Encourage a diet containing 25 to 45 g of fiber daily.

  • Avoid long-term treatment with manganese-containing nutritional formulations.


This thoughtful consensus paper highlights how important it is for clinicians to be cognizant of the nutritional status of their patients with cirrhosis as well as the importance of optimizing daily energy and protein intake in these patients. The panel emphasized that dietary protein restriction is detrimental in this population and should be avoided, yet they observed that this practice is still widespread, which requires urgent attention. They also observed that no evidence shows benefits from zinc supplementation or probiotic use. Finally, the panel noted the continued existence of significant knowledge gaps in nutritional management of patients with cirrhosis that merit further research.

Editor Disclosures at Time of Publication

  • Disclosures for Atif Zaman, MD, MPH at time of publication Speaker’s bureau Bristol-Myers Squibb; Genentech; Gilead; Kadmon; Merck; Salix; Vertex


Reader Comments (3)

Paul David Other, Dermatology

Just in case anyone need to fill out a Nutritional Assesment form, I found a blank form in this link This site PDFfiller also has several related forms that you might find useful.

deepa Resident, Internal Medicine, PGIMER

Consensus recommendation given by ISHEN is scientific and evidence based. But the main challenge would be to ensure its implemention throughout the world. Since, the concept of protein restriction in cirrhotics is still prevalent in many part of world. Implementation should be strongly considered.

Ileana Antohe Other, Internal Medicine, University of Medicine and Pharmacy "Gr T Popa" Iasi, Romania

It would be of interest to emphasize , detail and disseminate the need of optimal protein intake in cirrothic encephalopathy (with practical examples of daily proteine intake equivalents) in general practice of clinicans involved in chirrothic patients' care. Internists and nurses should be aware of this changing practice.

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