Calories

Energy needs vary with each individual

30-35 kcal/kg dry weight for maintenance

35-45 kcal/kg dry weight for malnourished patients

150%-175% of predicted BEE (calculated on dry weight)

Protein

0.8-1.0 g/kg dry weight in compensated liver disease

1.5-2.0 g/kg dry weight in decompensated liver disease

0.6-1.0 g/kg dry weight for hepatic encephalopathy; consider use of BCAA-enriched formulas

Fat

25%-40% of calories
Consider moderate amounts of MCT oil when steatorrhea present

Carbohydrate

High complex and simple carbohydrate
Restrict simple carbohydrate if glucose intolerance is present

Sodium

2-4 g/day depending upon level of fluid retention

Fluid

1000-1500 mL/day if fluid retention or hyponatremia is present

Vitamins

Common vitamin deficiencies:

• Fat malabsorption leads to malabsorption of fat-soluble vitamins
• Vitamin A: Liver unable to synthesize retinol-binding protein
• Vitamin D: Decreased biliary excretion of 1,23-dihydroxycholecalciferol
• Vitamin E: Hyperlipidemias in cholestatic liver disease affect vitamin E because it is carried by lipoproteins
• B vitamins: Excess losses due to alcohol abuse

Note: Give water-soluble forms of fat-soluble vitamins if steatorrhea is present.

Minerals

Mineral bioavailability, tissue distribution, and toxicity can be affected by decreased liver production of their protein carriers

Manganese and copper are excreted in bile and can be affected by an interruption in enterohepatic circulation

Zinc stores commonly are depleted

Serum potassium, magnesium, and phosphorus levels may decrease as a result of diuretic administration, refeeding syndrome, malabsorption, or alcoholism

800-1200 mg calcium/day; give supplements to patients at high risk of developing bone mineral density loss