Non-medical approaches

In the 20th century, low-protein diets were routinely recommended for patients with cirrhosis, with the aim of decreasing intestinal ammonia production and of preventing exacerbations of hepatic encephalopathy (HE). An obvious consequence was the worsening of preexisting protein-energy malnutrition. So although traditional advice has been to limit dietary protein intake in patients with cirrhosis, protein restriction showed to essentially make no difference to symptoms and outcomes in HE. Malnutrition is often a more serious clinical problem than HE for many of these patients. Nitrogen metabolism plays a major role in the development of HE in patients with cirrhosis. Modulation of this relationship is key to the management of HE, but is not the only nutritional issue that needs to be addressed.1

It is currently thought that a mixed lacto-vegetarian diet should be favoured with excessive intake of meat (protein load) and alcohol avoided. Patients may suffer from a loss of appetite. Consumption of insufficient calories in HE patients favours protein catabolism and the formation of ammonia. Diets containing vegetable proteins appear to be better tolerated than diets rich in animal protein, especially proteins derived from red meats. This may be because of increased content of dietary fibre, which is a natural cathartic.1

Current International Society on Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) recommendations regarding energy/protein provision in cirrhotic patients with HE are as follows:2

  • Optimal daily energy intake 35-40 Kcal/kg ideal body weight (IBW)
  • Optimal daily protein intake 1.2-1.5 g/kg IBW
  • Small daily meals/late night snack
  • Diet rich in vegetable and dairy protein
  • Where necessary (e.g. in cases of protein intolerance), patients may take branched-chain amino acids (BCAA) to correct any amino acid balance

Diets rich in vegetables and dairy protein may be beneficial and are therefore recommended. The ISHEN recommendations regarding fibre and micronutrients in cirrhotic patients with HE are as follows:2

  • Encourage diets with 25-45 g fibre/day
  • Two-week course of multivitamins if malnutrition is severe
  • Correct hyponatremia slowly to avoid central pontine myelinolysis
  • Avoid formulations containing manganese


1. Merz Data on file.
Amodio P et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis:  International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1):325-36.