Since the late nineteenth century,
protein restriction has been shown to improve
hepatic encephalopathy. However,
malnutrition has been described in up to 60 % of cirrhotic patients and is associated with increased mortality. Furthermore, emerging clinical evidence has revealed that a large proportion of cirrhotic patients may tolerate normal
protein intake. However, approximately one third of cirrhotic patients with
hepatic encephalopathy may need a short course of
protein restriction, in addition to maximum medical
therapy, to ameliorate the
clinical course of their
hepatic encephalopathy. For patients with chronic
hepatic encephalopathy who are
protein-sensitive, modifying their sources of
nitrogen by using more
vegetable protein, less animal
protein, and
branched-chain amino acids may improve their
encephalopathy without further loss of lean body mass. In conclusion, among cirrhotics with
hepatic encephalopathy, modulation of normal
protein intake must take into account the patient's hepatic reserve, severity of
hepatic encephalopathy, and current nutritional status.