Applied nutritional investigationBCAA-enriched snack improves nutritional state of 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
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