Aktuelle Ernährungsmedizin 2011; 36(2): 121-135
DOI: 10.1055/s-0030-1266072
CME-Fortbildung
© Georg Thieme Verlag KG Stuttgart · New York

Ernährung bei Lebererkrankungen

Nutrition in Liver DiseaseM.  Plauth1 , T.  Schütz2
  • 1Klinik für Innere Medizin, Städtisches Klinikum Dessau
  • 2IFB Adipositaserkrankungen, Universitätsklinikum Leipzig
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
01. April 2011 (online)

Zusammenfassung

Ernährungszustand und Leberkrankheit beeinflussen sich gegenseitig. Leberfunktionen werden durch Mangelernährung beeinträchtigt und können durch Ernährungstherapie wieder verbessert werden. Insbesondere chronische Lebererkrankungen führen abhängig von ihrem klinischen Schweregrad zu einer prognostisch relevanten Mangelernährung. Vorhandensein und Ausmaß der Mangelernährung können klinisch ohne technische Verfahren diagnostiziert werden. Bei schweren akuten Lebererkrankungen unterscheiden sich Indikation und Durchführung der Ernährungstherapie nicht wesentlich von denen aus anderer Ursache kritisch Erkrankter. Bei chronischen Leberkrankheiten ist der spontane Verzehr meist ungenügend und häufig besteht ein Eiweißmangel. In abgestuftem Vorgehen sollten Ernährungsberatung, ergänzende orale Trinknahrungen, enterale Sondennahrung und als Zweitlinientherapie die parenterale Ernährung eingesetzt werden. Die Ernährungstherapie mit Sicherstellung einer adäquaten Versorgung an Energie und Eiweiß kann Morbidität und Überleben verbessern.

Abstract

Nutritional status and liver disease influence each other. Liver function is compromized by malnutrition and this impairment can be overcome by nutritional intervention. Depending on disease severity, especially chronic liver disease leads to malnutrition which is an indicator of a poor prognosis. Both presence and degree of malnutrition can be diagnosed clinically without the need for techniqual equipment. In severe acute liver disease, indication and practice of nutritional therapy are not different from those in critically ill patients due to other etiology. In chronic liver disease, spontaneous food intake often is inadequate and frequently there is protein malnutrition. In a stepwise approach individualized dietary counselling, supplemental oral sip feeding, enteral tube feeding or parenteral nutrition as a second line option should be used. Nutritional therapy ensuring adequate provision of energy and protein can improve morbidity and mortality.

Literatur

  • 1 Child C G, Turcotte J G. Surgery and portal hypertension.. In: Child C G The liver and portal hypertension.. Philadelphia: Saunders; 1964: 50-51
  • 2 Plauth M, Merli M, Kondrup J et al. ESPEN guidelines for nutrition in liver disease and transplantation.  Clin Nutr. 1997;  16 43-55
  • 3 Selberg O, Böttcher J, Tusch G et al. Identification of high- and low-risk patients before liver transplantation: a prospective cohort study of nutritional and metabolic parameters in 150 patients.  Hepatology. 1997;  25 652-657
  • 4 Kondrup J, Müller M J. Energy and protein requirements of patients with chronic liver disease.  J Hepatol. 1997;  27 239-247
  • 5 Plauth M, Schütz T E. Nutrition in Liver Disease.. In: Banerjee, ed Nutritional Management of Digestive Diseases.. Boca Raton: CRC Press; 2010: 271-299
  • 6 Pirlich M, Schütz T, Spachos T et al. Bioelectrical impedance analysis is a useful bedside technique to assess malnutrition in cirrhotic patients with and without ascites.  Hepatology. 2000;  32 1208-1215
  • 7 Dharancy S, Lemyze M, Boleslawski E et al. Impact of impaired aerobic capacity on liver transplant candidates.  Transplantation. 2008;  86 1077-1083
  • 8 Plauth M. Gastroenterologie und Hepatologie.. In: Löser C Unter- und Mangelernährung.. Stuttgart: Thieme; 2011: 322-332
  • 9 Peng S, Plank L D, McCall J L et al. Body composition, muscle function, and energy expenditure in patients with liver cirrhosis: a comprehensive study.  Am J Clin Nutr. 2007;  85 1257-1266
  • 10 Laryea M, Watt K D, Molinari M et al. Metabolic syndrome in liver transplant recipients: prevalence and association with major vascular events.  Liver Transpl. 2007;  13 1109-1114
  • 11 Selberg O, Burchert W, van den Hoff J et al. Insulin resistance in liver cirrhosis. Positron-emission tomography scan analysis of skeletal muscle glucose metabolism.  J Clin Invest. 1993;  91 1897-1902
  • 12 Schütz T, Bechstein W O, Neuhaus P et al. Clinical practice of nutrition in acute liver failure – a European survey.  Clin Nutr. 2004;  23 975-982
  • 13 Müller M J, Böttcher J, Selberg O et al. Hypermetabolism in clinically stable patients with liver cirrhosis.  Am J Clin Nutr. 1999;  69 1194-1201
  • 14 Müller M J, Dettmer A, Tettenborn M et al. Metabolic, endocrine, haemodynamic and pulmonary responses to different types of exercise in individuals with normal or reduced liver function.  Eur J Appl Physiol Occup Physiol. 1996;  74 246-257
  • 15 Weimann A, Kuse E R, Bechstein W O et al. Perioperative parenteral and enteral nutrition for patients undergoing orthotopic liver transplantation. Results of a questionnaire from 16 European transplant units.  Transpl Int. 1998;  11 (S 01) S289-S291
  • 16 Petrides A S, De Fronzo R A. Glucose and insulin metabolism in cirrhosis.  J Hepatol. 1989;  8 107-114
  • 17 Clemmesen J O, Hoy C-E, Kondrup J et al. Splanchnic metabolism of fuel substrates in acute liver failure.  J Hepatol. 2000;  33 941-948
  • 18 Plauth M, Cabré E, Campillo B et al. ESPEN Guidelines Parenteral Nutrition. Liver Disease.  Clin Nutr. 2009;  28 436-444
  • 19 Clemmesen J O, Kondrup J, Ott P. Splanchnic and leg exchange of amino acids and ammonia in acute liver failure.  Gastroenterology. 2000;  118 1131-1139
  • 20 Ballmer P E, Walshe D, McNurlan M A et al. Albumin synthesis rates incirrhosis: correlation with Child-Turcotte Classification.  Hepatology. 1993;  18 292-297
  • 21 Plauth M, Cabré E, Riggio O et al. DGEM: Plauth M, Ferenci P, Holm E et al. ESPEN Guidelines on Enteral Nutrition: Liver Disease.  Clin Nutr. 2006;  25 285-294
  • 22 Plank L D, McCall J L, Gane E J et al. Pre- and postoperative immunonutrition in patients undergoing liver transplantation: a pilot study of safety and efficacy.  Clin Nutr. 2005;  24 288-296
  • 23 Cabré E, Rodriguez-Iglesias P, Caballeria J et al. Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial.  Hepatology. 2000;  32 36-42
  • 24 Kearns P J, Young H, Garcia G et al. Accelerated improvement of alcoholic liver disease with enteral nutrition.  Gastroenterology. 1992;  102 200-205
  • 25 Morgan T R, Moritz T E, Mendenhall C L et al. Protein consumption and hepatic encephalopathy in alcoholic hepatitis. VA Cooperative Study Group #275.  J Am Coll Nutr. 1995;  14 152-158
  • 26 Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management.  Lancet Neurol. 2007;  6 442-455
  • 27 Cabré E, González-Huix F, Abad A et al. Effect of total enteral nutrition on the short-term outcome of severely malnourished cirrhotics: a randomized controlled trial.  Gastroenterology. 1990;  98 715-720
  • 28 Plauth M, Schütz T, Buckendahl D P et al. Weight gain after transjugular intrahepatic portosystemic shunt is associated with improvement in body composition in malnourished patients with cirrhosis and hypermetabolism.  J Hepatol. 2004;  40 228-233
  • 29 Le Cornu K A, McKiernan F J, Kapadia S A et al. A prospective randomized study of preoperative nutritional supplementation in patients awaiting elective orthotopic liver transplantation.  Transplantation. 2000;  69 1364-1369
  • 30 Swart G R, Zillikens M C, van Vuure J K et al. Effect of a late evening meal on nitrogen balance in patients with cirrhosis of the liver.  Br Med J. 1989;  299 1202-1203
  • 31 Plank L D, Gane E J, Peng S et al. Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial.  Hepatology. 2008;  48 557-566
  • 32 Keohane P P, Attrill H, Grimble G et al. Enteral nutrition in malnourished patients with hepatic cirrhosis and acute encephalopathy.  J Parenter Enteral Nutr. 1983;  7 346-350
  • 33 Córdoba J, López-Hellín J, Planas M et al. Normal protein for episodic hepatic encephalopathy: results of a randomized trial.  J Hepatol. 2004;  41 38-43
  • 34 Horst D, Grace N D, Conn H O et al. Comparison of dietary protein with an oral, branched chain-enriched amino acid supplement in chronic portal-systemic encephalopathy: a randomized controlled trial.  Hepatology. 1984;  4 279-287
  • 35 Marchesini G, Bianchi G, Merli M et al. Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial.  Gastroenterology. 2003;  124 1792-1801
  • 36 Muto Y, Sato S, Watanabe A et al. Effects of oral branched chain amino acid granules on event-free survival in patients with liver cirrhosis.  Clin Gastroenterol Hepatol. 2005;  3 705-713
  • 37 Marchesini G, Fabbri A, Bianchi G et al. Zinc supplementation and amino acid-nitrogen metabolism in patients with advanced cirrhosis.  Hepatology. 1996;  23 1084-1092
  • 38 Druml W, Fischer M, Pidlich J et al. Fat elimination in chronic hepatic failure: long-chain vs medium-chain triglycerides.  Am J Clin Nutr. 1995;  61 812-817
  • 39 Naylor C D, O’Rourke K, Detsky A S et al. Parenteral nutrition with branched-chain amino acids in hepatic encephalopathy. A meta-analysis.  Gastroenterology. 1989;  97 1033-1042
  • 40 Als-Nielsen B, Koretz R L, Kjaergard L L et al. Branched-chain amino acids for hepatic encephalopathy.  Cochrane Database Syst Rev. 2003;  CD001939
  • 41 Olde Damink S W, Dejong C H, Deutz N E et al. Upper gastrointestinal bleeding: an ammoniagenic and catabolic event due to the total absence of isoleucine in the haemoglobin molecule.  Med Hypotheses. 1999;  52 515-519
  • 42 Olde Damink S WM, Jalan R, Deutz N EP et al. Isoleucine infusion during „simulated” upper gastrointestinal bleeding improves liver and muscle protein synthesis in cirrhotic patients.  Hepatology. 2007;  45 560-568
  • 43 Plank L D, Mathur S, Gane E J et al. Perioperative immunonutrition in liver transplantation: Results of a double-blind randomized controlled trial.  Clin Nutr Suppl. 2010;  5 (S 02) 3
  • 44 Chin S E, Shepherd R W, Thomas B J et al. Nutritional support in children with end-stage liver disease: a randomized crossover trial of a branched-chain amino acid supplement.  Am J Clin Nutr. 1992;  56 158-163

Prof. Dr. Mathias Plauth

Klinik für Innere Medizin
Städtisches Klinikum Dessau

Auenweg 38

06847 Dessau

eMail: mathias.plauth@klinikum-dessau.de