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Dr. Brown:
This is CE on ReachMD, and I'm Dr. Robert Brown from Weill Cornell in New York.

What's one of the biggest misconceptions about nutrition in patients with hepatic encephalopathy? Well, there are many, and most of them have to do with protein. We have to know that both hepatic encephalopathy, or HE, is a negative prognostic indicator for outcome. But the other negative prognostic indicator for outcome is sarcopenia, or muscle loss. And the third element is the 2 are related. The more muscle loss you have, the more likely you are to have hepatic encephalopathy.

Why is that? Because skeletal muscle is part of how we can get rid of ammonia and other nitrogenous waste, and so we want to preserve muscle mass. And so the common misconception is that patients with cirrhosis, especially those with hepatic encephalopathy, should be on a protein-restricted diet to prevent the increased ammonia load. Well, that makes sense in some aspects, but is clearly wrong because the adverse effect of protein restriction on muscle loss and sarcopenia overwhelms any impact it has on lowering the ammonia load.

So patients with cirrhosis, if anything, need more protein. I recommend 1.2 to 1.5 g/kg of protein intake daily. So if you think about that, for a 60-kg person, which is the lowest weight, would be between 70 and 90 g/day, spaced throughout the day, including a late-night high-protein snack, because patients have decreased energy storage in their liver.

Well, many of us are not comfortable with giving nutrition advice, and if so, that's fine, but then find a clinical dietitian or a nutritionist who can be a part of your patient's care team. There's a lot of information on the internet, but most of it will point to them restricting protein. They should only be using it to increase their protein intake.

Is any type of protein better? Yes, plant-based proteins, which have more branched-chain amino acids, are better than red meat protein. But what I tell my patients is, let's increase your plant protein as much as possible, try to work on the branched-chain amino acids, but don't let the restriction on animal protein lead to less protein intake.

Number one goal: get enough in. Number two goal: try to have as much plant protein as part of it. And it's better if it's in food than in supplements, but any way you get it done is most important.

That's the takeaway I wanted to leave you with. Thanks for listening.

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