Elsevier

Nutrition

Volume 23, Issue 2, February 2007, Pages 113-120
Nutrition

Applied nutritional investigation
BCAA-enriched snack improves nutritional state of cirrhosis

https://doi.org/10.1016/j.nut.2006.10.008Get rights and content

Abstract

Objective

A late evening snack improves the catabolic state in patients with advanced liver cirrhosis. We tested whether long-term (3 mo) late evening snacking that included a branched-chain amino acid (BCAA)–enriched nutrient mixture produces a better nutritional state and better quality of life than ordinary food in patients with hepatitis C virus–positive liver cirrhosis.

Methods

In a multicenter, randomized study, 48 patients with liver cirrhosis received late-evening supplementation with the BCAA-enriched nutrient mixture or ordinary food, such as a rice ball or bread, for 3 mo. During the study period, each patient was instructed on energy and protein intake. Blood biochemical data, nitrogen balance, respiratory quotient, and health-related quality of life (Short Form 36 questionnaire) were evaluated at baseline and at the end of the study.

Results

Total and late-evening energy intakes were similar in the two groups at 3 mo. Serum albumin level, nitrogen balance, and respiratory quotient were significantly improved by the BCAA mixture but not by ordinary food. The parameters of the Short Form 36 did not statistically significantly improve over 3 mo in either group.

Conclusion

Long-term oral supplementation with a BCAA mixture is better than ordinary food in a late evening snack at improving the serum albumin level and the energy metabolism in patients with cirrhosis.

Introduction

The liver plays an important role in energy metabolism. Patients with cirrhosis lack adequate glycogen stores because of liver atrophy and therefore develop a severe catabolic state after fasting. Owen et al. [1] reported that, after an overnight fast, patients with cirrhosis have a marked decrease in glucose oxidation, with enhanced fat and protein catabolism similar to that observed in healthy subjects after 2 to 3 d of starvation. To avoid such nocturnal starvation, energy supplements have been developed [2], [3], [4], [5] and are recommended as late evening snacks (LESs) in current American Society for Parenteral and Enterel Nutrition [6] and European Society for Clinical Nutrition and Metabolism [7] guidelines. Carbohydrate-rich snacks have been used previously in LESs, but some recent studies have indicated that a LES with a branched-chain amino acid (BCAA)–enriched nutrient mixture (BCAA mixture) can also improve the oxidation of aberrant substrates in the early morning in patients with cirrhosis [8], [9]. However, these studies have focused solely on the short-term effect of LESs on energy metabolism, and there have been no studies on the long-term outcome of LESs. Another important question that has not been answered is whether or not LESs should accompany BCAA supplementation.

Supplementation with BCAAs has mainly been attempted as a nutritional intervention for decompensated liver cirrhosis. Clinical evidence about the efficacy of this therapy has accumulated particularly in the past 3 y [10], [11], [12], [13] and indicates that BCAA supplementation raises the serum albumin level and improves the quality of life (QOL) and survival of patients with decompensated liver cirrhosis. A laboratory study also supports the view that BCAA regulates albumin synthesis at a subcellular level [14]. However, there are also many criticisms against BCAA administration in cirrhosis [15]. To confirm its efficacy, if any, supplementation conditions, including dose, time, and use of energy, might be further optimized. In this context, it is relevant that BCAA supplementation at night improved the nitrogen balance compared with daytime administration [16].

Therefore, we investigated which would be better to improve energy malnutrition, an ordinary LES or a BCAA-enriched LES.

Section snippets

Patients

Forty-eight patients with liver cirrhosis were recruited from 16 centers between April 2003 and June 2004. The study protocol was approved by the ethics committee of each hospital, and informed consent was obtained from each subject. Liver cirrhosis was diagnosed by documented laboratory data and/or histology. The patients were graded according to the Child-Pugh classification. Eligibility criteria were 1) positive test results for the hepatitis C virus antibody and 2) a serum albumin level

Clinical course

Forty-eight patients were initially enrolled and randomized (Fig. 2). However, one patient in the BCAA group opted for other treatments and declined. Therefore, the supplementation was initiated in 24 patients in the BCAA group and 23 patients in the snack group. During the study period of 3 mo, five patients in the BCAA group and four in the snack group were lost to follow-up. One patient in the BCAA group died from a cause unrelated to liver disease (cerebral bleeding). Two patients in the

Discussion

This study was performed to test the feasibility of the BCAA mixture, in comparison with ordinary food, as a LES in patients with cirrhosis. The results indicate that the LES with the BCAA mixture, but not with ordinary food, significantly improved nutritional parameters. The BCAA mixture improved the catabolic state (low npRQ), as expected (Table 5). Further, the BCAA mixture raised the nitrogen balance (Table 4) and serum albumin level (Table 3) in patients with cirrhosis when compared with

Conclusions

A BCAA mixture as a LES is a favorable nutritional intervention for liver cirrhosis to repair hypercatabolism and improve nutritional states, such as nitrogen balance and serum albumin. Symptoms and QOL could have recovered, but this effect requires confirmation by future studies.

Acknowledgment

In addition to the authors, the investigators in the Hepatic Nutrition Therapy Study Group included: Isao Sakaida, Katsuko Tasaka, Yamaguchi University School of Medicine; Takako Konno, Iwate Medical University, School of Medicine; Hideki Fukushima, Makoto Shiraki, Gifu University School of Medicine; Shohei Matsuzaki, Honami Fujii, Tokai University School of Medicine, Hachioji Hospital; Keiko Shiratori, Eiji Tatematsu, Tokyo Women’s Medical University; Michitaka Kojiro, Ikuko Ookubo, Ehime

References (33)

Cited by (184)

  • Nutritional Management of a Liver Transplant Candidate

    2023, Journal of Clinical and Experimental Hepatology
  • Efficacy of branched chain amino acids supplementation in liver cirrhosis: A systematic review and meta-analysis

    2022, Clinical Nutrition
    Citation Excerpt :

    BCAAs were not more efficacious than other interventions in decreasing % of body fat and only showed a trend in reducing mortality among cirrhotic patients. Seventeen studies [20–28,30–34,37–39] evaluated the effect of BCAA supplementation in albumin serum concentration, which can be regarded as an trustworthy indicator of patient's protein state and acts as an independent prognostic factor [40]. Our analysis showcased a significant effect in change from baseline albumin concentration in patients under BCAA supplementation, after excluding the only trial [37] reporting results with percentage changes.

View all citing articles on Scopus
View full text