ESPEN Guidelines on Parenteral Nutrition: Hepatology

SummaryParenteral 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 SteatohepatitisSubjectRecommendationsGradeNumberGeneralUse simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.C1Start PN immediately in moderately or severely malnourished ASH patients, who cannot be fed sufficiently either orally or enterally.A1Give i.v. glucose (2–3 g kg−1 d−1) when patients have to abstain from food for more than 12 h.C1Give PN when the fasting period lasts longer than 72 h.C1EnergyProvide energy to cover 1.3 × REEC2Give glucose to cover 50–60 % of non-protein energy requirements.C3Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions.C3Amino acidsProvide amino acids at 1.2–1.5 g kg−1 d−1.C3MicronutrientsGive water soluble vitamins and trace elements daily from the first day of PN.C3Administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy.C3MonitoringEmploy repeat blood sugar determinations in order to detect hypoglycemia and to avoid PN related hyperglycemia.C6Monitor phosphate, potassium and magnesium levels when refeeding malnourished patients.C3Summary of statements: Liver CirrhosisSubjectRecommendationsGradeNumberGeneralUse simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition.C4Start PN immediately in moderately or severely malnourished cirrhotic patients, who cannot be fed sufficiently either orally or enterally.A4Give i.v. glucose (2–3 g kg−1 d−1) when patients have to abstain from food for more than 12 h.C4Give PN when the fasting period lasts longer than 72 h.C4Consider PN in patients with unprotected airways and encephalopathy when cough and swallow reflexes are compromised.C4Use early postoperative PN if patients cannot be nourished sufficiently by either oral or enteral route.A4After liver transplantation, use early postoperative nutrition; PN is second choice to EN.C4EnergyProvide energy to cover 1.3 x REEC5Give glucose to cover 50 % - 60 % of non-protein energy requirements.C6Reduce glucose infusion rate to 2–3 g kg−1 d−1 in case of hyperglycemia and use consider the use of i.v. insulin.C6Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions.C6Amino acidsProvide amino acids at 1.2–1.5 g kg−1 d−1.C7In encephalopathy III° or IV°, consider the use of solutions rich in BCAA and low in AAA, methionine and tryptophane.A7MicronutrientsGive water soluble vitamins and trace elements daily from the first day of PN.C8In alcoholic liver disease, administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy.C3, 8MonitoringEmploy repeat blood sugar determinations in order to avoid PN related hyperglycemia.A6Monitor phosphate, potassium and magnesium levels when refeeding malnourished patients.C8Summary of statements: Acute Liver FailureSubjectRecommendationsGradeNumberGeneralCommence artificial nutrition when patient is unlikely to resume normal oral nutrition within the next 5–7 days.C9Use PN when patients cannot be fed adequately by EN.C9EnergyProvide energy to cover 1.3 × REE.C10Consider using indirect calorimetry to measure individual energy expenditure.C10Give i.v. glucose (2–3 g kg−1 d−1) for prophylaxis or treatment of hypoglycaemia.C11In case of hyperglycaemia, reduce glucose infusion rate to 2–3 g kg−1 d−1 and consider the use of i.v. insulin.C11, 6Consider using lipid (0.8 – 1.2 g kg−1 d−1) together with glucose to cover energy needs in the presence of insulin resistance.C11Amino acidsIn acute or subacute liver failure, provide amino acids at 0.8–1.2 g kg−1 d−1.C11MonitoringEmploy repeat blood sugar determinations in order to detect hypoglycaemia and to avoid PN related hyperglycaemia.C11Employ repeat blood ammonia determinations in order to adjust amino acid provision.C11Full-size tableTable optionsView in workspaceDownload as CSV