Protein-Controlled Diet
Manual of Clinical Nutrition Management G- 2 Copyright © 20 13 Compass Group, Inc.
Vitamins and minerals: Hepatic injury results in decreased absorption, transport, and storage and may
alter the metabolism of vitamins and minerals. Cirrhotic livers have been reported to store decreased
levels of thiamin; folate; riboflavin; niacin; pantothenic acid; vitamins B 6 , B 12 , and A; zinc; and cobalt (1,4).
In chronic liver disease, the hydroxylation of dietary and endogenous vitamin D to the active form (25-
hydroxy derivative) is impaired and may lead to a deficiency state with concomitant osteomalacia.
Although there are possibilities of vitamin and mineral deficiencies, supplementation should be
administered only when a specific nutrient deficiency is identified. Supplementation should be
monitored. Vitamin K deficiency may be induced from malabsorption with steatorrhea, dietary
deficiency, impaired hepatic storage, and/or decreased production of gut flora due to intake of
antibiotics. If vitamin K deficiency occurs, the rate at which prothrombin is converted to thrombin is
affected, thus hampering the coagulation process and producing inadequate clotting factors (1).
Intravenous or intramuscular vitamin K often is given for 3 days to rule out hypopothrombinemia due to
deficiency (4).
Nutritional Adequacy
Diets containing less than 50 g of protein may be inadequate in thiamin, riboflavin, calcium, niacin,
phosphorus, and iron based on the Statement on Nutritional Adequacy in Section IA. Supplementation may
be indicated but should be assessed on an individual basis. This diet should be considered a transitional diet.
Normal protein intake should be resumed soon after the cause of encephalopathy has been identified and
treated. Long-term protein restriction should only be considered in patients with refractory encephalopathy
(3).
How to Order the Diet
The diet order should specify the grams of protein required from food. Base the grams of protein ordered on
the patient’s actual weight or use ideal body weight in cases where weight cannot be measured or accurately
accessed due to fluid issues (e.g, with ascites). To calculate weight, see Section II (Estimation of Energy
Expenditures, or Weight for Height Calculation – 5’ Rule). If a special formula is requested, the amount should
be specified. Specify any restriction such as sodium, fluid, or other nutrients.
Planning the Diet
The table below outlines the recommended nutrient prescription according to type of hepatic disease (3,5,6).
Type of Hepatic Disease Nutrient Prescription
Fatty liver/steatosis Abstinence from ethanol
Weight reduction, if attributable to obesity
Reduced energy and dextrose intake, especially if patient is receiving total
parenteral nutrition (PN)
Hepatitis
(acute/chronic/alcoholic)
Energy: 30 – 35 kcal/kg
Protein: 1 – 1.2 g/kg
50 mg elemental Zinc may improve hepatic fibrosis (3)Cirrhosis
(uncomplicated)
Energy: 30 – 35 kcal/kg or RMR x 1.2 to 1.4 (3)
Protein: 1 – 1.2 g/kg
Supplementing 50 mg elemental Zinc may improve hepatic fibrosis (3)
Evaluate Vitamin D and thiamine for supplementation (3)^Cirrhosis
(complicated)
Energy: 30 – 35 kcal/kg or RMR x 1.2 to 1.4 (3)
Protein: 1 – 1.5 g/kg (with malnutrition)
Supplementing 50 mg elemental Zinc may improve hepatic fibrosis (3)
Evaluate Vitamin D and thiamine for supplementation (3)Esophageal varices Liberal diet consistency, normal consistency is encouraged as tolerated