Elsevier

Clinical Nutrition

Volume 28, Issue 4, August 2009, Pages 436-444
Clinical Nutrition

ESPEN Guidelines on Parenteral Nutrition: Hepatology

https://doi.org/10.1016/j.clnu.2009.04.019Get rights and content

Summary

Parenteral nutrition (PN) offers the possibility to increase or to ensure nutrient intake in patients, in whom sufficient nutrition by oral or enteral alone is insufficient or impossible. Complementary to the ESPEN guideline on enteral nutrition of liver disease (LD) patients the present guideline is intended to give evidence-based recommendations for the use of PN in LD. For this purpose three paradigm conditions of LD were chosen: alcoholic steatohepatitis (ASH), liver cirrhosis and acute liver failure. The guideline was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was presented on the ESPEN website and visitors' criticism and suggestions were welcome and included in the final revision. PN improves nutritional state and liver function in malnourished patients with ASH. PN is safe and improves mental state in patients with cirrhosis and severe HE. Perioperative (including liver transplantation) PN is safe and reduces the rate of complications. In acute liver failure PN is a safe second-line option to adequately feed patients in whom enteral nutrition is insufficient or impossible.

Summary of statements: Alcoholic Steatohepatitis
SubjectRecommendationsGradeNumber
GeneralUse simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.C1
Start PN immediately in moderately or severely malnourished ASH patients, who cannot be fed sufficiently either orally or enterally.A1
Give i.v. glucose (2–3 g kg−1 d−1) when patients have to abstain from food for more than 12 h.C1
Give PN when the fasting period lasts longer than 72 h.C1
EnergyProvide energy to cover 1.3 × REEC2
Give glucose to cover 50–60 % of non-protein energy requirements.C3
Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions.C3
Amino acidsProvide amino acids at 1.2–1.5 g kg−1 d−1.C3
MicronutrientsGive water soluble vitamins and trace elements daily from the first day of PN.C3
Administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy.C3
MonitoringEmploy repeat blood sugar determinations in order to detect hypoglycemia and to avoid PN related hyperglycemia.C6
Monitor phosphate, potassium and magnesium levels when refeeding malnourished patients.C3
Summary of statements: Liver Cirrhosis
SubjectRecommendationsGradeNumber
GeneralUse simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.C4
Start PN immediately in moderately or severely malnourished cirrhotic patients, who cannot be fed sufficiently either orally or enterally.A4
Give i.v. glucose (2–3 g kg−1 d−1) when patients have to abstain from food for more than 12 h.C4
Give PN when the fasting period lasts longer than 72 h.C4
Consider PN in patients with unprotected airways and encephalopathy when cough and swallow reflexes are compromised.C4
Use early postoperative PN if patients cannot be nourished sufficiently by either oral or enteral route.A4
After liver transplantation, use early postoperative nutrition; PN is second choice to EN.C4
EnergyProvide energy to cover 1.3 x REEC5
Give glucose to cover 50 % - 60 % of non-protein energy requirements.C6
Reduce glucose infusion rate to 2–3 g kg−1 d−1 in case of hyperglycemia and use consider the use of i.v. insulin.C6
Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions.C6
Amino acidsProvide amino acids at 1.2–1.5 g kg−1 d−1.C7
In encephalopathy III° or IV°, consider the use of solutions rich in BCAA and low in AAA, methionine and tryptophane.A7
MicronutrientsGive water soluble vitamins and trace elements daily from the first day of PN.C8
In alcoholic liver disease, administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy.C3, 8
MonitoringEmploy repeat blood sugar determinations in order to avoid PN related hyperglycemia.A6
Monitor phosphate, potassium and magnesium levels when refeeding malnourished patients.C8
Summary of statements: Acute Liver Failure
SubjectRecommendationsGradeNumber
GeneralCommence artificial nutrition when patient is unlikely to resume normal oral nutrition within the next 5–7 days.C9
Use PN when patients cannot be fed adequately by EN.C9
EnergyProvide energy to cover 1.3 × REE.C10
Consider using indirect calorimetry to measure individual energy expenditure.C10
Give i.v. glucose (2–3 g kg−1 d−1) for prophylaxis or treatment of hypoglycaemia.C11
In case of hyperglycaemia, reduce glucose infusion rate to 2–3 g kg−1 d−1 and consider the use of i.v. insulin.C11, 6
Consider using lipid (0.8 – 1.2 g kg−1 d−1) together with glucose to cover energy needs in the presence of insulin resistance.C11
Amino acidsIn acute or subacute liver failure, provide amino acids at 0.8–1.2 g kg−1 d−1.C11
MonitoringEmploy repeat blood sugar determinations in order to detect hypoglycaemia and to avoid PN related hyperglycaemia.C11
Employ repeat blood ammonia determinations in order to adjust amino acid provision.C11

Section snippets

Indication and time of PN in ASH

Immediate commencement of PN is indicated in ASH patients with moderate or severe malnutrition, who cannot be fed sufficiently either orally or enterally (A).

ASH patients who can be fed sufficiently either by oral or enteral route but who have to abstain from food temporarily (including nocturnal fasting!) for more than 12 h, should be given i.v. glucose at 2-3 g kg1 d1 (C). When this fasting period lasts longer than 72 h total PN is required (C).

Comments: The prognostic significance of a poor

Indication and timing of PN in cirrhosis

Immediate commencement of PN is indicated in moderately or severely malnourished cirrhotics who cannot be nourished sufficiently by either oral or enteral route (C).

Cirrhotics who can be fed sufficiently either by the oral or enteral route but who have to abstain from food temporarily (including nocturnal fasting!) for more than 12 h should be given i.v. glucose at 2–3 g kg−1 d−1 (C). When this fasting period lasts longer than 72 h total PN is required (C).

PN should be considered in patients with

Acute liver failure

Preliminary remarks: due to the substantial loss of liver cell function, acute liver failure (LF) is a serious condition characterised by profound metabolic dysfunction and is almost invariably complicated by multiple organ failure. Depending on the interval between the onset of jaundice and that of HE, hyperacute (interval < 8 days), acute (interval < 29 days) and subacute liver failure (interval 29–72 days) are distinguished.121 There is a more favourable prognosis in hyperacute than in acute or

Conflict of interest

Conflict of interest on file at ESPEN ([email protected]).

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