ARTICLE IN PRESS

Clinical Nutrition (2006) 25, 285-294

htt !""intl#$l%$&i$rh$alth#co'"(ournal%"clnu

ESPEN )*I+ELINES

ESPEN )ui,$lin$% on Ent$ral Nutrition! Li&$r ,i%$a%$$

-# Plautha, , E# Ca.r$., /# Ri00ioc, -# A%%i%1Ca'ilo,, 2 -# Pirlich $, 3# 4on,ru 5, +)E-!$$ P# 6$r$nci, E# 7ol', S# &o' +ahl, -#3# -u , 8# Nolt$ 9ll$r
a

+$ art'$nt Int$rnal -$,icin$, Sta$,ti%ch$% 4lini:u', +$%%au, )$r'an; +$ art'$nt o5 )a%tro$nt$rolo0;, 7o% ital <<)$r'an% Tria% i Pu(ol<<, =a,alona, S ain c +$ art'$nt o5 )a%tro$nt$rolo0; II, *ni&$r%ita <<La Sa i$n>a<<, Ro'a, Ital; 2 , C$ntr$ o5 Nutrition an, -$ta.oli%', -$,ical 6acult;, *ni&$r%it; o5 Li%.on Li%.on, Portu0al $ +$ art'$nt o5 )a%tro$nt$rolo0;, CC-, Charit$ *ni&$r%ita 2 9t%'$,i>in, =$rlin )$r'an; 5 Clinical Nutrition *nit 5?@@, Ri0%ho% ital$t, Co $nha0$n, +$n'ar:
.

R$c$i&$, 2@ 3anuar; 2006A acc$ t$, 2@ 3anuar; 2006

4EB8/R+S
)ui,$lin$A Clinical ractic$A E&i,$nc$1.a%$,A Ent$ral nutritionA /ral nutritional %u l$'$nt%A Tu.$ 5$$,in0A Li&$r cirrho%i%A AS7A NAS7A Acut$ li&$r 5ailur$A

Su''ar; Ent$ral nutrition (EN) .; '$an% o5 oral nutritional %u l$'$nt% (/NS) an, tu.$ 5$$,in0 (T6) o55$r% th$ o%%i.ilit; to incr$a%$ or to in%ur$ nutri$nt inta:$ in ca%$ o5 in%u55ici$nt oral 5oo, inta:$# Th$ r$%$nt 0ui,$lin$ i% int$n,$, to 0i&$ $&i,$nc$1.a%$, r$co''$n,ation% 5or th$ u%$ o5 /NS an, T6 in ati$nt% Cith li&$r ,i%$a%$ (L+)# It Ca% ,$&$lo $, .; an int$r,i%ci linar; $D $rt 0rou in accor,anc$ Cith o55iciall; acc$ t$, %tan,ar,% an, i% .a%$, on all r$l$&ant u.lication% %inc$ @985# Th$ 0ui,$lin$ Ca% ,i%cu%%$, an, acc$ t$, in a con%$n%u% con5$r$nc$# EN .; '$an% o5 /NS i% r$co''$n,$, 5or ati$nt% Cith chronic L+ in Cho' un,$rnutrition i% &$r; co''on# /NS i' ro&$ nutritional %tatu% an, %ur&i&al in %$&$r$l; 'alnouri%h$, ati$nt% Cith alcoholic h$ atiti%# In ati$nt% Cith cirrho%i%, T6 i' ro&$% nutritional %tatu% an, li&$r 5unction, r$,uc$% th$ rat$ o5 co' lication% an, rolon0% %ur&i&al# T6 co''$nc$, $arl; a5t$r li&$r tran% lantation can r$,uc$

A..r$&iation%! Nor'al 5oo,, Nor'al ,i$t o5 an in,i&i,ual a% o55$r$, .; th$ cat$rin0 %;%t$' o5 a ho% ital inclu,in0 % $cial ,i$t% $#0# 0lut$n15r$$, lacto%$ 5r$$ $tc# ,i$t%A AS7, Alcoholic %t$atoh$ atiti%A =CAA, =ranch$, chain a'ino aci,%A =IA, =io$l$ctric i' $,anc$ anal;%i%A EN, Ent$ral nutrition# Thi% i% u%$, a% a 0$n$ral t$r' to inclu,$ .oth /NS an, tu.$ 5$$,in0# 8h$n $ith$r o5 th$%$ 'o,aliti$% i% .$in0 ,i%cu%%$, %$ arat$l; thi% i% % $ci5i$, in th$ t$DtA LC, li&$r cirrho%i%A NAS7, Non1alcoholic %t$atoh$ atiti%A /NS, /ral nutritional %u l$'$nt%A S)A, Su.($cti&$ 0lo.al a%%$%%'$ntA T6, Tu.$ 5$$,in0 $ 6or 5urth$r in5or'ation on '$tho,olo0; %$$ Schut> $t al# 55 6or 5urth$r in5or'ation on ,$5inition o5 t$r'% %$$ Loch% $t al# 56 9 Corr$% on,in0 author# T$l#! E49 F40 50@@2?5A 5aD! E49 F40 50@@2@0# E1'ail a,,r$%%! 'athia%# lauthG:lini:u'1,$%%au#,$ (-# Plauth)# $$Th$ author% o5 th$ +)E- ()$r'an Soci$t; 5or Nutritional -$,icin$) 0ui,$lin$% on $nt$ral nutrition in li&$r ,i%$a%$ ar$ ac:noCl$,0$, 5or th$ir contri.ution to thi% articl$# 026@156@4"H 1 %$$ 5ront 'att$r & 2006 Euro $an Soci$t; 5or Clinical Nutrition an, -$ta.oli%'# All ri0ht% r$%$r&$,# ,oi!@0#@0@6"(#clnu#2006#0@#0@8

ARTICLE IN PRESS
286
*n,$rnutritionA =CAA

-# Plauth $t al#
co' lication rat$ an, co%t an, i% r$5$ra.l$ to ar$nt$ral nutrition# In acut$ li&$r 5ailur$ T6 i% 5$a%a.l$ an, u%$, in th$ 'a(orit; o5 ati$nt%# Th$ 5ull &$r%ion o5 thi% articl$ i% a&aila.l$ at CCC#$% $n#or0# & 2006 Euro $an Soci$t; 5or Clinical Nutrition an, -$ta.oli%'# All ri0ht% r$%$r&$,#

Su''ar; o5 %tat$'$nt%! Alcoholic %t$atoh$ atiti% R$co''$n,ation% Su.($ct *%ar 'Ito,o% ,$ ca.$c$ira %i' l$%, co'o o Su.($ti&o A&aliaJKo )lo.al (S)A) ou antro o'$tria ara )$n$ral i,$nti5icar aci$nt$% $' ri%co ,$ ,$%nutriJKo# R$co'$n,a,a a in0$%tKo ,$ $n$r0ia! F5140 :cal " :0 PC " , (@4?1@68 :3 " =8 40 " ,) R$co'$n,a,a a in0$%tKo ,$ rot$Lna%! @,21@,5 0 " :0PM " *%$ nutriJKo $nt$ral %u l$'$ntar Nuan,o o% aci$nt$% nKo o,$ %ati%5a>$r a% %ua% n$c$%%i,a,$% calOrica% atra&I% ,o% ali'$nto% nor'al# A lication +$ u' 'o,o 0$ral, %u l$'$nto% nutricionai% oral I r$co'$n,a,a# *%$ a ali'$ntaJKo or %on,a %$ o% aci$nt$% nKo %Ko ca a>$% ,$ 'ant$r in0$%tKo oral a,$Nua,a ('$%'o Nuan,o $%o5P0ico &ari>$% $%tKo r$%$nt$%) Rout$ ColocaJKo ,$ PE) $%tP a%%ocia,o co' u' 'aior ri%co ,$ co' licaJQ$%, $ nKo I r$co'$n,a,a## 6Or'ula% ,$ rot$Lna% int$0rai% %Ko 0$ral'$nt$ r$co'$n,a,o# Con%i,$r$ o u%o ,$ 5Or'ula% ,$ alta $n$r0ia 'ai% conc$ntra,a% $' aci$nt$% co' a%cit$# *%$ 5Or'ula% $nriNu$ci,a% co' =CAA $' aci$nt$% co' $nc$5alo atia h$ Ptica ,$corr$nt$ ,urant$ a nutriJKo $nt$ral#

)ra,$55 C

Nu'.$r @#@

C C A

@#F @#F @#2

= A

@#F @#F

C C C A

@#F @#F @#F @#F

T; $ o5 5or'ula

)ra,$! )ra,$ o5 r$co''$n,ationA Nu'.$r! r$5$r% to %tat$'$nt nu'.$r Cithin th$ t$Dt# Su''ar; o5 %tat$'$nt%! Li&$r cirrho%i% (LC) R$co''$n,ation% Su.($ct *%ar 'Ito,o% ,$ ca.$c$ira %i' l$%, co'o o Su.($ti&o A&aliaJKo )lo.al (S)A) ou antro o'$tria ara )$n$ral i,$nti5icar aci$nt$% $' ri%co ,$ ,$%nutriJKo# *%$ Rn0ulo ,$ 5a%$ ou cIlula ,o cor o '$,i,o $' 'a%%a or anPli%$ ,a i' $,Rncia .io$lItrica (=IA) ara Nuanti5icar ,$%nutriJKo, a $%ar ,$ al0u'a% li'itaJQ$% $' aci$nt$% co' a%cit$# R$co'$n,a,a a in0$%tKo ,$ $n$r0ia! F5140 :cal " :0PM " , (@4?1@68 :3 " :0=C " ,) R$co'$n,a,a a In0$%tKo ,$ Prot$Lna%! @,21@,5 0 " :0PM " ,*tili>$ $nt$ral %u l$'$ntar a nutriJKo Nuan,o o% aci$nt$% A lication nKo o,$ %ati%5a>$r a% %ua% n$c$%%i,a,$% calOrica% atra&I% ,$ &ia oral

)ra,$55 C

Nu'.$r 2#@

2#@

C C A

2#F 2#F 2#2

ARTICLE IN PRESS
ESPEN )ui,$lin$% on Ent$ral Nutrition 5oo, ,$% it$ a,$Nuat$ in,i&i,uali%$, nutritional a,&i%$# I5 ati$nt% ar$ not a.l$ to 'aintain a,$Nuat$ oral inta:$ 5ro' nor'al 5oo,, u%$ , /ral nutritional %u l$'$nt% or , Tu.$ 5$$,in0 ($&$n in th$ r$%$nc$ o5 o$%o ha0$al &aric$%) PE) lac$'$nt i% a%%ociat$, Cith a hi0h$r ri%: o5 co' lication% an, i% not r$co''$n,$,# 8hol$ rot$in 5or'ula$ ar$ 0$n$rall; r$co''$n,$,# Con%i,$r u%in0 'or$ conc$ntrat$, hi0h1$n$r0; 5or'ula$ in ati$nt% Cith a%cit$%# *%$ =CAA1$nrich$, 5or'ula$ in ati$nt% Cith h$ atic $nc$ halo ath; ari%in0 ,urin0 $nt$ral nutrition# Th$ u%$ o5 oral =CAA %u l$'$ntation can i' ro&$ clinical outco'$ in a,&anc$, cirrho%i%# Ent$ral nutrition i' ro&$% nutritional %tatu% an, li&$r 5unction, r$,uc$% co' lication% an, rolon0% %ur&i&al in cirrhotic% an, i% th$r$5or$ r$co''$n,$,# 28?

Rout$

C A C C C A = A

2#F 2#F 2#F 2#F 2#F 2#F 2#F 2#4

T; $ o5 5or'ula

/utco'$

)ra,$! )ra,$ o5 r$co''$n,ationA Nu'.$r! r$5$r% to %tat$'$nt nu'.$r Cithin th$ t$Dt#

Su''ar; o5 %tat$'$nt%! Tran% lantation an, %ur0$r; R$co''$n,ation% Su.($ct *%ar 'Ito,o% ,$ ca.$c$ira %i' l$%, co'o o Su.($ti&o A&aliaJKo )lo.al (S)A) ou antro o'$tria ara )$n$ral i,$nti5icar aci$nt$% $' ri%co ,$ ,$%nutriJKo# *%$ Rn0ulo ,$ 5a%$ ou cIlula ,o cor o '$,i,o $' 'a%%a or i' $,Rncia .io$lItrica anPli%$ ara Nuanti5icar ,$%nutriJKo, a $%ar ,$ al0u'a% li'itaJQ$% $' aci$nt$% co' a%cit$# In,ication Pr$o $rati&$ Po%to $rati&$ 6olloC r$co''$n,ation% 5or cirrho%i%# Initiat$ nor'al 5oo,"$nt$ral nutrition Cithin @2-24 h o%to $rati&$l;# Initiat$ $arl; nor'al 5oo, or $nt$ral nutrition a5t$r oth$r %ur0ical roc$,ur$%# 6olloC r$co''$n,ation% 5or cirrho%i%# 6or chil,r$n aCaitin0 tran% lantation con%i,$r =CAA a,'ini%tration# R$co''$n,$, $n$r0; inta:$! F5-40 :cal":0=8", (@4?-@68 :3":0=8",) R$co''$n,$, rot$in inta:$! @#2-@#5 0":0=8", 6olloC r$co''$n,ation% 5or cirrho%i%# *%$ na%o0a%tric tu.$% or cath$t$r ($(uno%to'; 5or $arl; $nt$ral nutrition#

)ra,$55 C

Nu'.$r F#@

F#@

F#2 = = F#2 F#2

lication Pr$o $rati&$

= C C

F#F F#F F#F

Po%to $rati&$

Rout$ Pr$o $rati&$ Po%to $rati&$

F#F

ARTICLE IN PRESS
288 T; $ o5 5or'ula Pr$o $rati&$ Po%to $rati&$ -# Plauth $t al#

6olloC r$co''$n,ation% 5or cirrho%i%# 8hol$ rot$in 5or'ula$ ar$ 0$n$rall; r$co''$n,$,# In ati$nt% Cith a%cit$% r$5$r conc$ntrat$, hi0h1 $n$r0; 5or'ula$ 5or r$a%on% o5 Sui, .alanc$# *%$ =CAA1$nrich$, 5or'ula$ in ati$nt% Cith h$ atic $nc$ halo ath; ari%in0 ,urin0 $nt$ral nutrition# An i' ro&$'$nt o5 $rio $rati&$ 'ortalit; or co' lication rat$ .; r$o $rati&$ tu.$ 5$$,in0 or oral nutritional %u l$'$nt% ha% not ;$t .$$n %hoCn# 7oC$&$r, a cl$ar r$co''$n,ation 5or nutritional C th$ra ; in un,$rnouri%h$, ati$nt% Cith li&$r cirrho%i% i% %u ort$, .; th$ %tat$'$nt% conc$rnin0 nutrition in LC 'a,$ in %tat$'$nt 2#4# C C A

F#F F#F F#F F#F

/utco'$ Pr$o $rati&$

F#4

Po%to $rati&$

Earl; nor'al 5oo, or $nt$ral nutrition i% r$co''$n,$, 5or tran% lant an, %ur0$r; ati$nt% Cith LC in or,$r to 'ini'i%$ $rio $rati&$Tin articular in5$ctiou%Tco' lication%#

F#4

)ra,$! )ra,$ o5 r$co''$n,ationA Nu'.$r! r$5$r% to %tat$'$nt nu'.$r Cithin th$ t$Dt#

@ # 7$ atit$ nKo alcoOlica ( AS7 )

/.%$r&aJQ$% r$li'inar$% ! NKo $Di%t$' $%tu,o% ran,o'i>a,o% controla,o% ,i% onL&$i% $' t$ra ia nutricional na $%t$ato1h$ atit$ nKo alcoOlica ( NAS7) # Ao contrPrio alcoOlico $%t$atoh$ atit$ ( AS7 ) , NAS7 'uita% &$>$% I co' o&$rnutrition $ r$%i%tUncia V in%ulina 1 cia,o a%%o # Portanto r$co'$n,aJQ$% ,a,a% ara AS7 nKo o,$ %$r 5acil'$nt$ a lica,a a NAS7 a $%ar ,a% %$'$lhanJa% notP&$i%# R$co'$n,aJQ$% nutricionai% ara aci$nt$% NAS7 5ocar a ,o$nJa ,$ .a%$ (%Ln,ro'$ '$ta.Olica, outra% cau%a% %$cun,Pria% ) # @#@ # S$rP Nu$ a in5luUncia ,o $%ta,o nutricional r$%ulta,o $' AS7 W Xual I o '$lhor 'Ito,o a' la'$nt$ a licP&$l ara a&aliar o $%ta,o nutricional W / &alor ro0nO%tico ,o $%ta,o nutricional ,$ aci$nt$% co' h$ atit$ alcoOlica 5oi ,$'on%tra,a ( III ) # -Ito,o% %i' l$% ,$ ca.$c$ira co'o a A&aliaJKo Su.($ti&a )lo.al ( S)A ) ou antro o'$tria %Ko con%i,$ra,o% a,$Nua,o% ara a i,$nti5icaJKo ,$ aci$nt$% $' ri%co (C)# Co'$ntPrio! MPria% u.licaJQ$% ,a A'$rican A%%unto% ,$ M$t$rano% (MA) r$latOrio ,o $%tu,o ,$ u'a 'aior taDa ,$ co' licaJQ$% $ 'ortali,a,$ $' AS7 %u.nutri,a aci$nt$%#@ 1F A 5i' ,$ i,$nti5icar a ,$%nutriJKo , u' %i%t$'a ,$ ontuaJKo Nu$ con%i%t$ ,$ &ariP&$i% co'o $%o r$al " i,$al , antro o'$tria , cr$atinina
%

Ln,ic$, rot$Lna% &i%c$rai% , conta0$' a.%oluta ,$ lin5Ocito% , a r$aJKo ti o tar,io $l$ 5oi u%a,a n$%%$% $%tu,o%# E%t$ %i%t$'a ,$ ontuaJKo co' o%ta inclui &ariP&$i% nKo con5iP&$i% , co'o a% conc$ntraJQ$% la%'Ptica% ,$ rot$Lna% &i%c$rai% ou 24 h cr$atinina urinPria $Dcr$JKo $ 5oi 'o,i5ica,a &Pria% &$>$% , a 'ai% r$c$nt$ u.licaJKo ,a %Iri$ ta'.I' r$latara' u' %i0ni5ica,o ro0nO%tico ,a% &ariP&$i% a.%oluta C+8 E contar $ 'Ko a,$rUncia %tr$n0th#F AlI' ,i%%o, u'a clara a%%ociaJKo $ntr$ a .aiDa in0$%tKo ,o nor'al ali'$nto% $ alta 'ortali,a,$ 5oi 5oun,#2 @#2 # Xuan,o I in,ica,o PT ou contra W NutriJKo $nt$ral Su l$'$ntar ( PT ) I in,i 1 ca,o Nuan,o o% aci$nt$% A%h nKo o,$ %ati%5a>$r a% %ua% n$c$%%i,a,$% calOrica% atra&I% ,o% ali'$nto% nor'al ( A) $ , Nuan,o nKo hP contra1in,icaJQ$% , co'o Ll$o (C)# Co'$ntPrio! E%ta% r$co'$n,aJQ$% %Ko .a%$a,a% $' %$i% $n%aio% Nu$ $%tu,a' na EN 465 aci$nt$% AS7 ,@ 16 ,$ Nu$ a $na% trU% $n%aio% 5ora' ran,o'i%$,4 16 ( I.)# /% $%tu,o% a'$ricano% MA co' arou o% $5$ito% ,$ $%t$rOi,$% ana.oli>ant$% &$r%u% lac$.o $' con(unto co' o% $5$ito% ,$ %u l$'$nto% nutricionai% orai% ,$ alta $n$r0ia $ rot$Lna (/NS) $nriNu$ci,a co' a'inoPci,o% ,$ ca,$ia ra'i5ica,a 1a'ino (=CAA) &% .aiDo /NS#2 $n$r0ia $ rot$Lna , F A u.licaJQ$% ,$ @99F"@995 contU' u'a a&aliaJKo con(unta $ r$%u'in,o o% $%tu,o% MA Y 2?5 $ Y @@9 Nu$ (P ha&ia' %i,o u.lica,o

ARTICLE IN PRESS
ESPEN )ui,$lin$% on Ent$ral Nutrition %$ ara,a'$nt$, @ $ o% r$%ulta,o% ,$%%a% u.licaJQ$% %Ko, ortanto, ,i5Lc$i% ,$ int$r r$t#@1F El$% 'o%tra', orI', Nu$ u'a in0$%tKo ,$ $n$r0ia $ rot$Lna 'ai% $l$&a,a o,$ %$r con%$0ui,a $lo /NS ou ali'$ntaJKo or %on,a (T6), '$%'o $' aci$nt$% %$&$ra'$nt$ ,$%nutri,a% AS7# E'.ora PT ar$c$ %$r r$5$rL&$l ara nutriJKo ar$ntIrica, nKo hou&$ 0ran,$ $n%aio, ran,o'i>a,o, co' aran,o o% ,oi% 'Ito,o% $' aci$nt$% AS7# E' r$%u'o, o% r$%ulta,o% ,$%t$% $%tu,o% 'o%tra', Nu$ co' l$'$ntar PT a%%$0ura $n$r0ia a,$Nua,a $ in0$%tKo ,$ rot$Lna, %$' o ri%co ,$ co' licaJQ$%, tai% co'o a $nc$5alo atia h$ Ptica (I.)# @#F# Co'o ,$&$ %$r $ntr$0u$ PTW 1 2hich formula3 , 2hich method of deli#er43 , 2hat dosage3 2hole protein formulae are generall4 recomremendado (&) +e alta energia mais concentrada f"rmulas so prefer#eis em pacientes com ascite para e#itar saldo positi#o de fluidos (&) 5&(( f"rmulas enriquecidas de#e ser utili!ado em papacientes com encefalopatia heptica decorrente durante PT (() ,m geral, so recomendados 6$7 (5) 7e os pacientes no so capa!es de manter a ingesto oral adequada, T8 9 recomendada (mesmo quando #ari!es esofgicas esto presentes) (() &olocao de P,: est associado com um maior risco de complicaes (de#ido a ascite ou #ari!es) e no 9 recomendada (&) ( ingesto de energia de ;<-=> ?cal @ ?gPA @ d (B=C-B1/ ?D @ ?gPA @ d) e um consumo de protena de B,.-B,< g @ ?gPA @ d are recommended (&) Co'$ntPrio! 5Or'ula% $nriNu$ci,a% co' =CAA 5ora' u%a,o% $' o MA a'$ricano $%tu,a,@1F, $nNuanto Nu$ outro% $%tu,o% utili>a,o% ca%$in5 ou rot$Lna intacta co' =CAA a,icional co'o u' %ourc$#6 a>oto *'a co' araJKo ,ir$ta $ntr$ 5Or'ula a,rKo $ =CAA 5Or'ula $nriNu$ci,a ain,a nKo 5oi 5$ita ,$ 'o,o Nu$ a% r$co'$n,aJQ$% 0$rai% nKo o,$ %$r 5$ita %o.r$ o &alor ,$ 5Or'ula% $nriNu$ci,a% co' =CAA $' aci$nt$% cin>a%# R$co'$n,aJQ$% a r$% $ito ,a Nuanti,a,$ ,$ nu1tri$nt$% %Ko ,$ri&a,o% ,$ tho%$@1F, 5,6 ,a,a $' $%tu,o% u.lica,o% (I=)# NKo hP n$nhu'a $&i,Uncia na atual lit$ratura619 (I.) Nu$ &ari>$% $%o5P0ica% r$ r$%$nta' NualNu$r ri%co ara o u%o ,$ cali.r$ 5ino %on,a na%o0P%trica ara T6# @#4# / PT '$lhorar o $%ta,o nutricional, 5L0a,o u 289 PT garante a ingesto de energia e protena adequada, sem o risco de complicaes, como a encefalopatia heptica (Ib) PT foi to efica! como os ester"ides em pacientes com hepatite alco"lica gra#e $o entanto, sobre#i#entes que tinham sido tratados com PT mostraram uma menor ta%a de mortalidade no ano seguinte &omentrio' ( influ)ncia da PT na clnica curso da doena do fgado (*+) no pode ser considerada satisfat"ria a partir dos dados dispon#eis ,m um estudo controlado com placebo mised-rando nenhuma diferena em ./ - foi encontrado no diamortalidade entre os grupos que receberam PT e os ester"ides recebendo $este 0ltimo no entanto, a ta%a de mortalidade de#ido a complicaes infecciosas no ano seguinte foi higher (I.)# *' o%%L&$l $5$ito %inIr0ico ,o% ,oi% trata'$nto% ,$&$' %$r in&$%ti0a,o%# Nu'a a&aliaJKo co'.ina,a ,$ ,oi% $%tu,o% a'$ricana MA (a $na% u' al$atori>a,o) u'a r$,uJKo %i0ni5icati&a na 'ortali,a,$ 5oi $ncontra,o no %u.0ru o ,aNu$l$% 5unJKo $ ro0nO%ticoW aci$nt$% 0ra&$'$nt$ ,$%nutri,a% Nu$ alcanJara' u'a in0$%tKo a,$Nua,a ,$ /NS#2 / %u.1 0ru o ,$ aci$nt$% co' ,$%nutriJKo 'o,$ra,a , r$c$.$n,o a oDan,rolona $%t$rOi,$ $ t$ra ia nutricional $nriNu$ci,a co' =CAA , ti&$ra' u' r$%ulta,o '$lhor ,o Nu$ o 0ru o Nu$ r$c$.$u a oDan,rolona alon$#2 E%t$% r$%ulta,o% %u0$r$' Nu$ a,$Nua,o in0$%tKo nutricional I u' rI1r$Nui%ito ara u' $5$ito o%iti&o ,o trata'$nto ,$ oDan,rolona # AtI a0ora , nKo $Di%t$' ro&a% ,$ Nu$ a PT t$' NualNu$r i' acto %o.r$ a 5unJKo h$ Ptica $' a%h2 , 6 ( IIa ) # AlI' ,i%%o a&aliaJKo ,o .anco ,$ ,a,o% MA 'o%trou Nu$, $' aci$nt$% cu(o% AS7 $nc$5alo atia o,$ %$r controla,a co' o trata'$nto a,rKo, co'o lactu 1 $r,$, a .aiDa in0$%tKo ,$ rot$Lna 5oi a%%ocia,a a u' a0ra&a'$nto ,a $nc$5alo atia ao a%%o Nu$ u'a in0$%tKo nor'al ,$ rot$Lna% ( @ 0 " :0PM " , ) 5oi a%%ocia,o co' u' a'$lioration8 , @0 ( I. ) #

2 # A cirro%$ h$ Ptica (LC) 2#@ # S$rP Nu$ a in5luUncia ,o $%ta,o nutricional r$%ulta,o $' aci$nt$% co' LC W Xual I a '$lhor a' la'$nt$ 'Ito,o a licP&$l ara a&aliar o $%ta,o nutricional W A ,$%nutriJKo a5$ta n$0ati&a'$nt$ o ro0nO%tico $' aci$nt$% co' LC ( III ) # -Ito,o% ,$ ca.$c$ira %i' l$%, co'o o S)A o

ARTICLE IN PRESS
290 Co'$ntPrio! MPrio% $%tu,o% ,$%criti&o% r$lata' taDa% ,$ alta $r ,$ co' licaJQ$% $ 'ortali,a,$ or LC aci$nt$% co' ,$%nutriJKo 0ra&$ , a%%i' co'o 'aior 'ortali,a,$ , co'o 5L0a,o tran% lant$ ,$ tion#@@ 1 20 Para a i,$nti5icaJKo ,$ 'Ito,o% ,$ ,$%nutriJKo ,$ ca.$c$ira , co'o o S)A ou antro o'$tria ou '$,iJKo ,$ unho %tr$n0th2@ %Ko con%i,$ra,a% a,$Nua,a% , o u%o ,$ $%cor$% co' o%to% nKo ro orcionar NualNu$r a,icional &alu$#22 -$,iJKo Nuantitati&a r$ci%a ,o $%ta,o nutricional I ,i5Lcil na r$%$nJa ,$ %o.r$car0a ,$ 5lui,o% ou %Lnt$%$ r$(u,ica,a h$ Ptica ,$ rot$Lna% ( or $D$' lo, al.u'ina) 2F $ n$c$%%ita ,$ 'Ito,o% %o5i%tica,o% , tai% co'o a conta0$' total ,o cor o ,$ otP%%io, a.%orcio'$tria ,$ ,u la $'i%%Ko ,$ raio% 1Z ( +EZA) , in &i&o n$u 1 anPli%$ or ati&aJKo tron ( IMNAA ) $ ,iluiJKo i%otO ica 1 tion#22 Entr$ o% 'Ito,o% ,$ ca.$c$ira ,$ '$,ir o $%ta,o nutricional $' aci$nt$% co' cirro%$ , a ,$t$r'inaJKo ,o Rn0ulo ,$ u'a 5a%$ ou =C- u%an,o =IA I con%i,$ra,o %u $rior ao ,$ 'Ito,o% co'o antro1 o'$tr; $ 24 h ,$ cr$atinina $Dcr$JKo ,24 1 26 , a $%ar al0u'a% li'itaJQ$% $' aci$nt$% co' a%cit$%#2? , 28 2#2 # Xuan,o I in,ica,o PT ou contra W Su l$'$ntar PT I in,ica,a Nuan,o o% aci$nt$% LC nKo o,$ %ati%5a>$r %ua% n$c$%%i,a,$% nutricionai% na co'i,a nor'al a $%ar ,o acon%$lha'$nto nutricional in,i&i,uali>a,a a,$Nua,a (A)# Co'$ntPrio! LC aci$nt$% ,$&$' atin0ir u'a $n$r0ia in0$%tKo ,$ F5140 :cal " :0=C " , ( @4?1@68 :3 " :0=C " , ) $ u'a in0$%tKo ,$ rot$Lna% ,$ @,21@,5 0":0=8",#@8 S$ .ucal in0$%tKo nKo I a,$Nua,o , a $%ar nutricional con%$lho 1 lin0, $ntKo /NS ou T6 a,icional ,$&$ %$r co'1 '$nc$, # E' aci$nt$% co' ,o$nJa a&anJa,a %$&$ra'$nt$ %u.nutri,a% LC %u l$'$ntar PT , $' a,iJKo ao nor'al ali'$nto a, li.itu' , I ,$ &alor? ,ocu'$nta,o , 8 ( I. ) # E' aci$nt$% co' LC '$no% a&anJa,o /NS a,icional nKo ro,u>iu r$%ulta,o% '$lhor$% ,o Nu$ co'i,a nor'al co'.ina,a co' coun%$llin029 nutricionai% (I=)# Ao ,$ci,ir o 'Ito,o 'ai% a,$Nua,o ,$ ali'$ntaJKo aci$nt$% co' $nc$5alo atia a&anJa,a, o ri%co ,$ a% iraJKo ,urant$ T6 ,$&$' %$r $%a,o% contra o% ot$nciai% co' licaJQ$% ,a nutriJKo ar$nt$ral# 2#F# 7oC %houl, EN .$ ,$li&$r$,W $, 2hich formula3 Th$; ar$ .a%$, on th$ in&$%ti0ation o5 rot$in , 2hich method of deli#er43 r$Nuir$'$nt o5 LC ati$nt%F? an, on th$ a'ount% o5 , 2hat dosage3 $n$r0; an, nitro0$n 0i&$n in int$r&$ntion %tu1 ,i$%#F,5-8,F0,F@ A r$c$ntl; u.li%h$, ran,o'i%$, 2hole protein formulae are generall4 recomtrialF8 ,$'on%trat$% that ,i$t% containin0 @#2 0 o5 mended (&) Iore concentrated high-energ4 rot$in can %a5$l; .$ a,'ini%t$r$, to ati$nt% Cith formulae are preferable in patients Eith ascites LC %u55$rin0 5ro' $ i%o,ic $nc$ halo ath; an, in order to minimise Juid o#erload (&)# thatT$&$n tran%i$ntT rot$in r$%triction ,o$% not -# Plauth $t al# 5&(( f"rmulas enriquecidas de#e ser usado em pacientes com encefalopatia heptica decorrente PT (() du-rante 7uplementao de 5&(( oral pode melhorar clnica resultado de cirrose a#anada (5) 7e os pacientes no so capa!es de manter adequada a ingesto oral de comida normal , 6$7 ( & ) ou T8 ( () ( mesmo na presena de #ari!es esofgicas) so recomendados &olocao de P,: est associado com um maior risco de complicaes , de#ido a ascite ou #ari!es , e no 9 recomendada ( & ) ( ingesto de energia de ;<-=> ?cal @ ?gPA @ d ( B=C-B1/ ?D @ ?g5E @ d ) e um consumo de B,.-B,< g de protena @ ?g5E @ d so recomendadas ( & ) &omentrio' 6s dados dispon#eis sugerem que a garantia de a ingesto de nutrientes em quantidade suficiente de#e ser o goal ; primrio ,<,C,/,.F - ;B (t9 recentemente , no ficou claro se uma f"rmula enriquecida em aminocidos de cadeia ramificada (5&(() 9 superior a uma f"rmula de protena inteira padro , uma #e! que a emisso apenas ha#ia sido in#estigada em um grupo altamente selecionado de protena pacientes *& intolerantes com achados encefalopatia - th4 ;. de um mais #elho descontrolado e dois estudos randomi!ados recentes, incluindo BC= e 1=1 pacientes sugerem que a suplementao de longa durao ( B. e .= meses ) com nutricional 5&(( oral, granu - final como 6$7 9 0til para retardar a progresso da insufici)ncia heptica e prolongando sem acontecimentos sobre#i - #al;; - ;< ( Ib ) ,m relao ao m9todo de inter#eno nutricional , nutricional alone.F aconselhamento ou em combinao com 6$7; , <,;B , muitas #e!es, ser bem sucedida 7e as necessidades de energia no podem ser satisfeitas , T8 9 re- quired C , /,;> Geser#as relati#as ao lugar -mento de sonda nasogstrica por causa de seu potencial para pro#ocar sangramento gastrointestinal no so suportados pelo atual literaturaC -F ( Ib) (scite , comprometimento do sistema de coagulao e portosist)mica circulao colateral de#ido H hipertenso portal t)m sido relatados como contra-indicaes es para P,: placement ;1 6s dados dispon#eis sobre energia e protena e%igem mentos so pesquisadas e recomenda-es apropriadas so feitas em uma antiga diretri! paper .. ,7P,

ARTICLE IN PRESS
ESPEN )ui,$lin$% on Ent$ral Nutrition con5$r$ NualNu$r .$n$5Lcio ara o% aci$nt$% ,urant$ u' $ %io,$ ,$ $nc halo ath; [ I. \ # 2#4 # / PT '$lhorar o $%ta,o nutricional , 5L0a,o 5unJKo ou ro0nO%ticoW PT '$lhora o $%ta,o nutricional $a 5unJKo ,$ 5L0a,o JKo , r$,u> co' licaJQ$% $ rolon0a %o.r$&i 1&al $' LC $, ortanto, I r$co'$n,a,o (A)# Co'$ntPrio! E%ta r$co'$n,aJKo .a%$ia1%$ no r$%ulta,o% ,$ cinco $n%aio% clLnico% ran,o'i>a,o% $' 245 a 1 ti$nt%5 , ?,8,29,F@ (I. ), ,o% Nuai% a 'aioria $ra' cirrOtico% alcoOlica%# El$ (P ha&ia %i,o 'o%tra,a $' t$%t$% in,i&i,uai% co' $Nu$no ta'anho ,a a'o%tra , Nu$, $' aci$nt$% LC PT '$lhora a 5unJKo h$ Ptica , ?,8 %tatu%29 nutricional $ %ur&i&al? (I.)# A artir ,$%%$% $%tu,o% , ar$c$ Nu$ a ,i'inuiJKo ,a 'ortali,a,$ o,$ %$r &i%to 'ai% 5acil'$nt$ Nuan,o u'a .aiDa in0$%tKo ,$ rot$Lna co' co'i,a nor'al no 0ru o control$ I co' ara,o co' u'a alta in0$%tKo ,$ rot$Lna na 0rou #F? int$r&$nJKo A O% o %uc$%%o ,o trata'$nto ,a hi $rt$n%Ko ortal intra1h$ Ptica tran%(u0ular or %t$nt 1 %hunt ( TIPS) , o% aci$nt$% LC %o.r$ co'i,a nor'al (,$ acor,o co' r$co'$n,aJQ$% E% $n ) 5ora' ca a>$% ,$ '$lhorar o %$u cor o co' o%ition#F9 , 40 29@ A 5i' ,$ i,$nti5icar a %u.nutriJKo , 'Ito,o% ,$ ca.$c$ira %i' l$%, tai% co'o PI) ou antro o'$tria %Ko .a%tant$ a,$Nua,o% # Co'o u' in,ica,or ,$ ro0nO%tico , a co'.inaJKo ,a ,i'inuiJKo =C- ( '$no% ,o Nu$ F5 _ ,a 'a%%a r$al ,o cor o , tal co'o a&alia,o $la =IA ) $ h; $r'$ 1 ta.oli%'20 , 4F r$c$.$u u'a a&aliaJKo 'ai% %i%t$'Ptica # 7i $r'$ta.oli%'o , no $ntanto , %O o,$ %$r a&alia,a or '$io ,$ calori'$tria in,ir$cto , o Nual nKo $%tP ,i% onL&$l $' to,o% o% ho% itai% # / u%o ,$ outro% $%cor$% co' o%to% nKo con5$r$ ro0nO%tico a,icional &alu$#22 F#2 # Xuan,o I in,ica,o PT ou contra W Paci$nt$% rI1o $ratOrio% ! Co'o r$co'$n,a,o ara LC aci$nt$% # Paci$nt$% no O%1o $ratOrio ! A O% tran% lant$ ,$ 5L0a,o 1 JKo , o ali'$nto nor'al $ " ou PT ,$&$rP %$r inicia,a ,$ntro ,$ @2124 h ,$ O%1o $ratOrio ( = ) # +$ oi% ,$ outro% roc$,i'$nto% cir`r0ico% , o% aci$nt$% co' L+ cr^nica ,$&$' r$c$.$r co'i,a nor'al c$,o ou PT co'o outro% 0ru o% ,$ aci$nt$% (=)# R$n,i'$nto% ,$ nutriJKo no O%1o $ratOrio r$%ulta,o% %u $rior$% V in5u%Ko ,$ 5lui,o% $ $l$ctrOlito% %O ( I. ) # +oa,or$% ,$ Or0Ko% ! N$nhu'a r$co'$n,aJKo $% $cL5ica o,$ %$r 5$ita $' r$laJKo V Oti'a ,oa,or ,$ Or0Ko% con,iciona,o# Co'$ntPrio! aci$nt$% rI1o $ratOrio% ! E'.ora o 6oi ,$'on%tra,o no ro0nO%tico ,$ ,$%nutriJKo $' can,i,ato% tran% 1 lanta , Nu$ ain,a nKo t$nha %i,o ,$'on%tra,o Nu$ a int$r&$nJKo nutricional rI '$lhora clinica'$nt$ r$%ulta,o% r$l$&ant$% # E' aci$nt$% co' LC '$no% a&anJa,o $ r$,o'inant$'$nt$ col$%tPtica, nKo hou&$ &anta0$' ,o /NS %o.r$ acon%$lha'$nto nutricional $ 5oo,29 nor'al ( I.)# Paci$nt$% no O%1o $ratOrio ! nutriJKo O%1o $ratOria $' aci$nt$% tran% lanta,o% I %u $rior V in5u%Ko ,$ 5lui,o% $ $l$trOlito% a $na% co' r$laJKo ao t$' o no &$ntila,or $ t$' o ,$ $r'anUncia na IC*44 (I=)# PT inicia,o tKo c$,o Nuanto @2 h a O% a o $raJKo $%tP a%%ocia,a a u'a '$nor taDa ,$ in5$cJKo ,o Nu$ nutrition45 ar$ntIrica ( I. ) # LC aci$nt$% tU' u'a taDa r$,u>i,a ,$ co' licaJQ$% $ 'aior $cono'ia ,$ nitro0Unio a O% a cirur0ia a.,o'inal , %$ r$c$.$r %u ort$ nutricional $' &$> ,$ a $na% ,$ lLNui,o% $ $l$ctrol;t$%46 148 (I.)# Po,$ %$r %$0ura'$nt$ a%%u'i,o Nu$ PT no inLcio ,o% r$n,i'$nto% O%1 o $ratOrio ain,a '$lhor$% r$%ulta,o% , orI' n$nhu' $%tu,o co' arou o% ,oi% r$0i'$% $' LC # 7P ,a,o% Nu$ %u0$r$' u' $5$ito .$nI5ico %o.r$ a $r'$a.ili,a,$ ,o int$%tino ,$ %$Na$ncial nutriJKo ar$nt$ral " PT (&ia ($(uno%to'ia ) $' r$laJKo V nutriJKo ar$nt$ral %o>inho ou n$nhu'a nutriJKo O%1o $ratOria $' all48 (I.)

F # Tran% lant$ $ cirur0ia (M$(a ta'.I' a% ,ir$tri>$% << Cirur0ia incl# ]r0Ko Tran%1 lantaJKo <<) # F#@ # S$rP Nu$ a in5luUncia ,o $%ta,o nutricional r$%ulta,oW Xual I o '$lhor 'Ito,o a' la'$nt$ a licP&$l ,$ a&aliaJKo ,o $%ta,o nutricional W / &alor ro0nO%tico ,a rI1o $ratOrio nutricional $%ta,o $' aci$nt$% tran% lanta,o% ,$ 5L0a,o t$' %i,o ,$'on%tra,a (I.)# -Ito,o% %i' l$% ,$ ca.$c$ira , co'o S)A ou antro1 o'$tr; %Ko con%i,$ra,o% a,$Nua,o% ara i,$nti5icar aci$nt$% $' ri%co (C)# +$ 'o,o a Nuanti5icar a %u.nutriJKo a ,$t$r'inaJKo ,o Rn0ulo ,$ u'a 5a%$ ou ,$ 'a%%a c$lular cor oral utili>an,o =IA I r$co'$n,a,o , a $%ar ,$ al0u'a% li'itaJQ$% $' aci$nt$% co' a%cit$ (=) # Co'$ntPrio! +a,o% ,$ aci$nt$% co' L+ cr^nica %u.'$ti,o% a cirur0ia Nu$ nKo %$(a o tran% lant$ h$ Ptico %Ko ouco%# E' &Prio% $%tu,o% ,$%criti&o% 'aior$% taDa% ,$ co' licaJQ$% $ 'ortali,a,$ %Ko r$lata,o% $' aci$nt$% co' ,$%nutriJKo rI1o $ratOria Nu$ %$ %u.'$t$' a tran% lant$ ara o t$r'inal cr^nica L+#@@ 1@F ,@? 1@9 , 4@ aci$nt$% LC %u.nutri,a% $%tKo $' 'aior ri%co ,$ co' licaJQ$% O%1o $ratOria% , incluin,o 'ortali,a,$ 'ai% $l$&a,a %$0uint$ %ur0$r;#42 a.,o'inal #

ARTICLE IN PRESS
292 / 5L0a,o 0or,uro%o I conh$ci,o or %$r u' 5ator ,$ ri%co ara o 'au 5unciona'$nto ,o $nD$rto ri'Prio# NKo $Di%t$' ,a,o% ,i% onL&$i% a.or,an,o o a $l ,a 0$%tKo nutricional ,o ,oa,or ,$ Or0Ko%# F#F# Co'o ,$&$ %$r $ntr$0u$ PTW , 2hich formula3 , 2hich method of deli#er43 , 2hat dosage3 -# Plauth $t al# Pacientes no p"s-operat"rio' comida normal &edo ou PT 9 recomendado para pacientes com transplante e cirurgia com *&, a fim de minimi!ar a peri-operat"ria em particulares infecto-complicaes (5) &omentrio' pacientes pr9-operat"rios' melhorar 6$7 #ari#eis antropom9tricas e funo muscular, mas a sobre#i#)ncia no global ap"s o transplante Nuan,o co' ara,o co' co'i,a nor'al co'.ina,a co' coun%$llin0#29 nutricionai% ,$%,$ Nu$ o ali'$nto nor'al $ nutricional chu'.o acon%$lha'$nto ara a '$%'a in0$%tKo a,$Nua,a co'o Nuan,o /NS %Ko a,iciona,o%, a'.o% o% r$0i'$% %Ko con%i,$ra,o% i0ual'$nt$ $5ica>$% (ou in$5ica>$%) mortalidade operat"ria ou ta%a de complicaes por T8 pr9-operat"rio ou 6$7 ainda no foi mostrado $o entanto, uma recomendao clara para a terapia nutricional em pacientes desnutridos *& 9 pelas declaraes relati#as H alimentao na *& feitas na declarao . = ( &) portado -sup AlI' ,i%%o, n$%t$ $%tu,o, nKo hou&$ 0ru o control$ %$' NualNu$r int$r&$nJKo , u'a &$> Nu$ t$ria %i,o antiItico co' .a%$ no atual conh$ci'$nto # Paci$nt$% no O%1o $ratOrio ! aci$nt$% tran% lanta,o% Nu$ r$c$.$ra' no inLcio PT @2 h a O% a cirur0ia ,$%$n&ol&$ra' '$no% in5$cJQ$% &irai% $ '$lhor r$t$ntion45 nitro0Unio (I=)# E' co' araJKo co' a nutriJKo ar$nt$ral , PT r$,u> a% taDa% ,$ co' licaJQ$% $ cu%to% $' ati$nt%5@ tran% lant$ (I=)#

Preoperati#e patients' 8or adults, the recom-

#mendations for *& are applicable 8or children aEaiting transplantation, the administration of 5&((enriched formulae should be considered (5, one randomised trial)# Pacientes no p"s-operat"rio ' f"rmulas de protenas inteiras so geralmente recomendadas ( & ) 8"rmulas de alta energia concentrados so prefer#eis em pacientes com ascite por ra!es de equilbrio de fluido ( & ) 5&(( f"rmulas enriquecidas de#e ser utili!ado em pa pacientes com encefalopatia heptica decorrente durante PT (() Para incio PT o uso de sonda nasogstrica ou cateter KeKunostomia 9 recomendado como em cirurgia no- *+ (5) (#er tamb9m as diretri!es LL &irurgia incl Mrgo transplante LL) ( ingesto de energia de ;<-=> ?cal @ ?gPA @ d ( B=C-B1/ ?D @ ?g5E @ d ) e um consumo de B,.-B,< g de protena @ ?g5E @ d so recomendadas ( & ) &omentrio' pacientes pr9-operat"rios ' Para adultos pa pacientes as recomendaes para *& aplicar Pacientes transplantados Pediatria - tric com *+ predominantemente colesttica mostram um melhor aumento de 5&I se receberem enriquecido em 5&(( formula=F ( Ib ) Pacientes no p"s-operat"rio ' ,%istem poucos estudos que abordam este tema 8"rmulas de protenas inteiras Eith<> ou sem pr9 e probiotics=< , <B ou f"rmulas H base de peptdeos #ia cateter KeKunost - om4<. , <; t)m sido utili!ados para o incio de PT dos receptores de transplante de fgado de adultos 8"rmulas foram administradas #ia sonda nasogstrica ou nasoduodenal ap"s placement<B endosc"pica ou #ia cateter KeKunost om4=/ , <.,<; colocada durante a laparotomia ; = 6 PT melhorar o estado nutricional , fgado funo e progn"stico3 Pacientes pr9-operat"rios ' uma melhoria na peri-

4 # In%u5iciUncia h$ Ptica 5ul'inant$ In%u5iciUncia h$ Ptica 5ul'inant$ , %$' trata'$nto ,$ r$ 1%ulta,o% $' 'ort$ ,$ntro ,$ ,ia%# E%ta.ili>aJKo ,o '$ta.oli%'o I o.ri0atOrio $ , n$%%a 5a%$ ,a ,o$nJa, I 'ai% i' ortant$ ,o Nu$ a t$ra ia nutricional &i%an,o at$n,$r ,iaria'$nt$ r$Nui%ito% # A hi o0lic$'ia I u' ,i%t`r.io '$ta.Olico 5r$Na$nt$ $ '$r$c$ at$nJKo $ t$ra ia articular, tai% co'o ( ar) 0lico%$ $nt$ral a,'ini%1traJKo (C)# Paci$nt$% co' in%u5iciUncia h$ Ptica a0u,a ,$&$ r$c$.$r PT atra&I% ,o tu.o na%o,uo,$nal ( C ) # NKo r$co'$n,a1JQ$% r$lati&a% a u'a co' o%iJKo $% $cL5ica ,o$nJa ,$ 5Or'ula% $ntIrica% o,$' actual'$nt$ %$r ,$t$r'ina,o ( C ) # A Nuanti,a,$ r$co'$n,a,a I ,$ 5Or'ula $ntIrica co' .a%$ na ,o%$ ,$ ,o$nJa 0ra&$ ( III ) # +$&i,o a u'a 5alha 0ra&$ ,o 5L0a,o , 0lico%$ , lactato, tri0lic$ri,o% $ a'^nia nL&$i% la%'Ptico% ,$&$' %$r cui,a,o%a'$nt$ 'onitori>a,o% $ utili>a,o% co'o 'arca,or$% %u.%tituto% ,a utili>aJKo ,o %u.%trato (C)# Co'$ntPrio! A o.%ta' ,a,o% ,i% onL&$i% $%ca%%o% NualNu$r r$co'$n,aJKo clara# E' r$conh$ci'$nto a $%%$ ,I5icit , u'a $%Nui%a 5oi r$ali>a,a $' c$ntro% ,$ h$ atolo0ia $uro $u% %o.r$ Nu$%tQ$% ,$ ar$nt$ral nut1 rition $' aci$nt$% co' ,o$nJa h$ Ptica 5ul'inant$ 5ailur$#54 *' r$%ulta,o i' ortant$ 5oi Nu$ c$ntro% co' u' T6 na%o,uo,$nal $l$&a,o n`'$ro ,$ ca%o% 5a&orP&$i% , o Nu$ o,$ria %$r r$ali>a,o co' %uc$%%o na

'aioria ,o% ca%o% #

ARTICLE IN PRESS
ESPEN )ui,$lin$% on Ent$ral Nutrition 29F
@8# 7arri%on 3, -c4i$rnan 3, N$u.$r0$r 3# A ro% $cti&$ %tu,; on th$ $55$ct o5 r$ci i$nt nutritional %tatu% on outco'$ in li&$r tran% lantation# Tran% lant Int @99?A@0!F69 -?4# @9# 6i0u$ir$,o 6, +ic:%on ER, Pa%ha T, $t al# I' act o5 nutritional %tatu% on outco'$% a5t$r li&$r tran% lantation# Tran% lanta1 tion 2000A?0!@F4?-52# 20# S$l.$r0 /, =ottch$r 3, Pirlich -, 7$n:$l E, -ann% -P, -ull$r -3# Clinical %i0ni5icanc$ an, corr$lat$% o5 Chol$ .o,; ota%%iu' %tatu% in ati$nt% Cith li&$r cirrho%i%# 7$ atol R$% @999A@999!F6-48# 2@# 6i0u$ir$,o 6, +ic:%on ER, Pa%ha T-, $t al# *tilit; o5 %tan,ar, nutritional ara'$t$r% in ,$t$ctin0 .o,; c$ll 'a%% ,$ l$tion in ati$nt% Cith $n,1%ta0$ li&$r ,i%$a%$# Li&$r Tran% lant 2000A6!5?5-8@# 22# Plauth -, -$rli -, 4on,ru 3, 6$r$nci P, 8$i'ann A, -ull$r -3# ESPEN 0ui,$lin$% 5or nutrition in li&$r ,i%$a%$ an, tran% lantation# Clin Nutr @99?A@6!4F -55# 2F# Pri(at'o:o +, Strau%% =3, La'.$rt 3R, $t al# Earl; ,$t$ction o5 rot$in ,$ l$tion in alcoholic cirrho%i%! rol$ o5 .o,; co' o%ition anal;%i%# )a%tro$nt$rolo0; @99FA@05!@8F9 -45# 24# Pirlich -, S$l.$r0 /, =o:$r 4, SchCar>$ -, -ull$r -3# Th$ cr$atinin$ a roach to $%ti'at$ %:$l$tal 'u%cl$ 'a%% in ati$nt% Cith cirrho%i%# 7$ atolo0; @996A24!@422 -?# 25# Pirlich -, Schut> T, S acho% T, $t al# =io$l$ctrical i' $,anc$ anal;%i% i% a u%$5ul .$,%i,$ t$chniNu$ to a%%$%% 'alnutrition in cirrhotic ati$nt% Cith an, Cithout a%cit$%# 7$ atolo0; 2000AF2!@208-@5# 26# S$l.$r0 /, S$l.$r0 +# Nor'% an, corr$lat$% o5 .ioi' $,anc$ ha%$ an0l$ in h$alth; hu'an %u.($ct%, ho% itali>$, ati$nt%, an, ati$nt% Cith li&$r cirrho%i%# Eur 3 A l Ph;%iol 2002A86!509-@6# 2?# )u0li$l'i 68, Cont$nto 6, La,,a0a L, Pan$lla C, 6ranca&illa A# =io$l$ctric i' $,anc$ anal;%i%! $D $ri$nc$ Cith 'al$ ati$nt% Cith cirrho%i%# 7$ atolo0; @99@A@F!892 -5# 28# Pan$lla C, )u0li$l'i 68, -a%tronu>>i T, 6ranca&illa A# 8hol$1.o,; an, %$0'$ntal .io$l$ctrical ara'$t$r% in chronic li&$r ,i%$a%$! $55$ct o5 0$n,$r an, ,i%$a%$ %ta0$%# 7$ atolo0; @995A2@!F52-8# 29# L$ Cornu 4A, -c4i$rnan 63, 4a a,ia SA, N$u.$r0$r 3-# A ro% $cti&$ ran,o'i>$, %tu,; o5 r$o $rati&$ nutritional %u l$'$ntation in ati$nt% aCaitin0 $l$cti&$ orthoto ic li&$r tran% lantation# Tran% lantation 2000A69!@F64 -9# F0# S'ith 3, 7oroCit> 3, 7$n,$r%on 3-, 7$;'%5i$l, S# Ent$ral h; $rali'$ntation in un,$rnouri%h$, ati$nt% Cith cirrho%i% an, a%cit$%# A' 3 Clin Nutr @982AF5!56 -?2# F@# 7ir%ch S, =unout +, ,$ la -P, $t al# Controll$, trial on nutrition %u l$'$ntation in out ati$nt% Cith %;' to'atic alcoholic cirrho%i%# 3 Par$nt$r Ent$ral Nutr @99FA@?!@@9 -24# F2# 7or%t +, )rac$ N+, Conn 7/, $t al# Co' ari%on o5 ,i$tar; rot$in Cith an oral, .ranch$, chain1$nrich$, a'ino aci, %u l$'$nt in chronic ortal1%;%t$'ic $nc$ halo ath;! a ran,o'i>$, controll$, trial# 7$ atolo0; @984A4!2?9 -8?# FF# Bo%hi,a T, -uto B, -oriCa:i 7, Ba'ato -# E55$ct o5 lon01t$r' oral %u l$'$ntation Cith .ranch$,1chain a'ino aci, 0ranul$% on th$ ro0no%i% o5 li&$r cirrho%i%# )a%tro$nt$rol 3a an @989A24!692 -8# F4# -arch$%ini ), =ianchi ), -$rli -, Th$ Italian =CAA Stu,; )rou , $t al# Nutritional %u l$'$ntation Cith .ranch$,1 chain a'ino aci,% in a,&anc$, cirrho%i%! a ,ou.l$1.lin,, ran,o'i>$, trial# )a%tro$nt$rolo0; 200FA@24!@?92 -80@# F5# -uto B, Sato S, 8atana.$ A, 5or th$ L/T*S 0rou , $t al# E55$ct% o5 oral .ranch$, chain a'ino aci, 0ranul$% on $&$nt1 5r$$ %ur&i&al in ati$nt% Cith li&$r cirrho%i%# Clin )a%tro1 $nt$rol 7$ atol 2005AF!?05-@F# F6# Lo 9%$r C, 6ol%ch *R# [)ui,$lin$% 5or tr$at'$nt Cith $rcu1 tan$ou% $n,o%co ic 0a%tro%to';# )$r'an Soci$t; o5

R$5$r$nc$%
@# -$n,$nhall CL, To%ch T, 8$$%n$r RE, $t al# MA co1 o $rati&$ %tu,; on alcoholic h$ atiti%# II! ro0no%tic %i0ni5icanc$ o5 rot$in1calori$ 'alnutrition# A' 3 Clin Nutr @986A4F!2@F-8# 2# -$n,$nhall CL, -orit> TE, Ro%$ll$ )A, $t al# A %tu,; o5 oral nutritional %u ort Cith oDan,rolon$ in 'alnouri%h$, ati$nt% Cith alcoholic h$ atiti%! r$%ult% o5 a ,$ art'$nt o5 &$t$ran% a55air% coo $rati&$ %tu,;# 7$ atolo0; @99FA @?!564-?6# F# -$n,$nhall CL, -orit> TE, Ro%$ll$ )A, $t al# Prot$in $n$r0; 'alnutrition in %$&$r$ alcoholic h$ atiti%! ,ia0no%i% an, r$% on%$ to tr$at'$nt# Th$ MA Coo $rati&$ Stu,; )rou Y2?5# 3 Par$nt$r Ent$ral Nutr @995A@9!258 -65# 4# Cal&$; 7, +a&i% -, 8illia'% R# Controll$, trial o5 nutritional %u l$'$ntation, Cith an, Cithout .ranch$, chain a'ino aci, $nrich'$nt, in tr$at'$nt o5 acut$ alcoholic h$ atiti%# 3 7$ atol @985A@!@4@-5@# 5# =unout +, Aicar,i M, 7ir%ch S, $t al# Nutritional %u ort in ho% itali>$, ati$nt% Cith alcoholic li&$r ,i%$a%$# Eur 3 Clin Nutr @989A4F!6@5-2@# 6# Ca.r$ E, Ro,ri0u$>1I0l$%ia%, Ca.all$ria 3, $t al# Short1 an, 2 lon01t$r' outco'$ o5 %$&$r$ alcohol1in,uc$, h$ atiti% tr$at$, Cith %t$roi,% or $nt$ral nutrition! a 'ultic$nt$r ran,o'i>$, trial# 7$ atolo0; 2000AF2!F6 -42# ?# Ca.r$ E, )on>al$>17uiD 6, A.a, A, $t al# E55$ct o5 total 2 2 $nt$ral nutrition on th$ %hort1t$r' outco'$ o5 %$&$r$l; 'alnouri%h$, cirrhotic%! a ran,o'i>$, controll$, trial# )a%tro$nt$rolo0; @990A98!?@5-98?20# 8# 4$arn% P3, Boun0 7, )arcia ), $t al# Acc$l$rat$, i' ro&$1 '$nt o5 alcoholic li&$r ,i%$a%$ Cith $nt$ral nutrition# )a%tro$nt$rolo0; @992A@02!200-5# 9# +$L$,in0h$n M, =$au P, -annant PR, $t al# Earl; 5$$,in0 or $nt$ral nutrition in ati$nt% Cith cirrho%i% a5t$r .l$$,in0 5ro' $%o ha0$al &aric$%W A ran,o'i>$, controll$, %tu,;# +i0 +i% Sci @99?A42!5F6-4@# @0# -or0an TR, -orit> TE, -$n,$nhall CL, 7aa% R# Prot$in con%u' tion an, h$ atic $nc$ halo ath; in alcoholic h$ atiti%# MA Coo $rati&$ Stu,; )rou Y2?5# 3 A' Coll Nutr @995A@4!@52-8# @@# -ou:ar>$l AA, Na(' I, Mar0a% 3, -c+iar'i, SM, =u%uttil R8, A'$nt -E# E55$ct o5 nutritional %tatu% on outco'$ o5 orthoto ic li&$r tran% lantation in $,iatric ati$nt%# Tran% lant Proc @990A22!@560-F# @2# Pi:ul 3, Shar $ -+, LoCn,$% R, )h$nt CN# +$0r$$ o5 r$o $rati&$ 'alnutrition i% r$,icti&$ o5 o%to $rati&$ 'or.i,it; an, 'ortalit; in li&$r tran% lant r$ci i$nt%# Tran% lantation @994A5?!469-?2# @F# 7arri%on 3, -c4i$rnan 3, N$u.$r0$r 3-# A ro% $cti&$ %tu,; on th$ $55$ct o5 r$ci i$nt nutritional %tatu% on outco'$ in li&$r tran% lantation# Tran% lant Int @99?A@0!F69 -?4# @4# Car$0aro L, Al.$rino 6, A'o,io P, $t al# -alnutrition in alcoholic an, &iru%1r$lat$, cirrho%i%# A' 3 Clin Nutr @996A 6F!602-9# @5# Al.$rino 6, )atta A, A'o,io P, $t al# Nutrition an, %ur&i&al in ati$nt% Cith li&$r cirrho%i%# Nutrition 200@A@?! 445-50# @6# -$rli -, Ri00io /, +all; L# +o$% 'alnutrition a55$ct %ur&i&al in cirrho%i%W PINC (Polic$ntrica Italiana Nutri>ion$ Cirro%i)# 7$ atolo0; @996A2F!@04@-6# @?# S$l.$r0 /, =ottch$r 3, Tu%ch ), Pichl'a;r R, 7$n:$l E, -ull$r -3# I,$nti5ication o5 hi0h1 an, loC1ri%: ati$nt% .$5or$ li&$r tran% lantation! a ro% $cti&$ cohort %tu,; o5 nutritional an, '$ta.olic ara'$t$r% in @50 ati$nt%# 7$ atolo0; @99?A25!652-?#

ARTICLE IN PRESS
294
+i0$%ti&$ an, -$ta.olic +i%$a%$%\# b )a%tro$nt$rol @996A F4!404-8# 4on,ru 3, -ull$r -3# En$r0; an, rot$in r$Nuir$'$nt% o5 ati$nt% Cith chronic li&$r ,i%$a%$# 3 7$ atol @99?A2?! F?# 2F9-4?# F8# Co 2r,o.a 3, Lo 2 $>17$llcn 3, Plana% -, $t al# Nor'al rot$in 2 5or $ i%o,ic h$ atic $nc$ halo ath;! r$%ult% o5 a ran,o1 'i>$, trial# 3 7$ atol 2004A4@!F8 -4F# F9# Allar, 3P, Chau 3, San,o:(i 4, =l$n,i% L-, 8on0 6# E55$ct% o5 a%cit$% r$%olution a5t$r %ucc$%%5ul TIPS on nutrition in cirrhotic ati$nt% Cith r$5ractor; a%cit$%# A' 3 )a%tro$nt$r1 ol 200@A96!2442-?# 40# Plauth -, Schut> T, =uc:$n,ahl +P, $t al# 8$i0ht 0ain a5t$r 9 TIPS i% a%%ociat$, Cith i' ro&$'$nt in .o,; co' o%ition in 'alnouri%h$, ati$nt% Cith cirrho%i% an, h; $r'$ta.oli%'# 3 7$ atol 2004A40!228 -FF# 4@# -ull$r -3, Laut> 7*, Plo0'ann =, =ur0$r -, 4or.$r 3, Sch'i,t 68# En$r0; $D $n,itur$ an, %u.%trat$ oDi,ation in ati$nt% Cith cirrho%i%! th$ i' act o5 cau%$, clinical %ta0in0 an, nutritional %tat$# 7$ atolo0; @992A@5!?82 -94# 42# )arri%on RN, Cr;$r 7-, 7oCar, +A, Pol: 3r 7C# Clari5ication o5 ri%: 5actor% 5or a.,o'inal o $ration% in ati$nt% Cith h$ atic cirrho%i%# Ann Sur0 @984A@99!648 -55# 4F# -ull$r -3, Lo;al S, SchCar>$ -, Lo.$r% 3, S$l.$r0 /, Rin0$ =# R$%tin0 $n$r0; $D $n,itur$ an, nutritional %tat$ in ati$nt% Cith li&$r cirrho%i% .$5or$ an, a5t$r li&$r tran%1 lantation# Clin Nutr @994A@F!@45 -52# 44# R$ill; 3, -$hta R, T$ $r'an L, $t al# Nutritional %u ort a5t$r li&$r tran% lantation! a ran,o'i>$, ro% $cti&$ %tu,;#

-# Plauth $t al#
4?# 4an$'at%u T, 4o;ana0i N, -at%u'ata T, 4itano S, Ta:$na:a 4, Su0i'achi 4# Lac: o5 r$&$nti&$ $55$ct o5 .ranch$,1chain a'ino aci, %olution on o%to $rati&$ h$ atic $nc$ halo1 ath; in ati$nt% Cith cirrho%i%! a ran,o'i>$,, ro% $cti&$ trial# Sur0$r; @988A@04!482 -8# 48# 7u X1), bh$n0 )1C# Th$ inSu$nc$ o5 $nt$ral nutrition in o%to $rati&$ ati$nt% Cith oor li&$r 5unction# 8orl, 3 )a%tro$nt$rol 200FA9!84F -6# 49# Chin SE, Sh$ h$r, R8, Tho'a% =3, $t al# Nutritional %u ort in chil,r$n Cith $n,1%ta0$ li&$r ,i%$a%$! a ran,o'i>$, cro%%o&$r trial o5 a .ranch$,1chain a'ino aci, %u l$'$nt# A' 3 Clin Nutr @992A56!@58-6F# 50# Ra;$% N, S$$ho5$r +, 7an%$n S, $t al# Earl; $nt$ral %u l; o5 lacto.acillu% an, 5i.$r &$r%u% %$l$cti&$ .oC$l ,$conta'ina1 tion! a controll$, trial in li&$r tran% lant r$ci i$nt%# Tran% lantation 2002A?4!@2F -?# 5@# 8ic:% C, So'a%un,ara' S, =(arna%on I, $t al# Co' ari%on o5 $nt$ral 5$$,in0 an, total ar$nt$ral nutrition a5t$r li&$r tran% lantation# Lanc$t @994AF44!8F? -40# 52# P$%co&it> -+, -$hta PL, L$a 'an S=, -il0ro' -L, 3in,al R-, 6ilo RS# Tu.$ ($(uno%to'; in li&$r tran% lant r$ci i$nt%# Sur0$r; @995A@@?!642-?# 5F# -$hta PL, Ala:a 43, 6ilo RS, L$a 'an S=, -il0ro' -L, P$%co&it> -+# Nutrition %u ort 5olloCin0 li&$r tran% lanta1 tion! co' ari%on o5 ($(unal &$r%u% ar$nt$ral rout$%# Clin Tran% lant @995A9!F64-9# 54# Schut> T, =$ch%t$in 8/, N$uhau% P, Loch% 7, Plauth -# 9 Clinical ractic$ o5 nutrition in acut$ li&$r 5ailur$ -a Euro $an %ur&$;# Clin Nutr 2004A2F!9?5-82#

3 Par$nt$r Ent$ral Nutr @990A@4!F86 -9@# 45# 7a%%$ 3-, =lu$ LS, Li$ a )*, $t al# Earl; $nt$ral nutrition %u ort in ati$nt% un,$r0oin0 li&$r tran% lantation# 3 Par$nt$r Ent$ral Nutr @995A@9!4F? -4F# 46# 6an ST, Lo C-, Lai EC, Chu 4-, Liu CL, 8on0 3# P$rio $rati&$ nutritional %u ort in ati$nt% un,$r0oin0 h$ at$cto'; 5or h$ atoc$llular carcino'a# N En0l 3 -$, @994AFF@!@54? -52#

55# Schut> T, 7$r.%t =, 4oll$r -# -$tho,olo0; 5or th$ ,$&$lo 1 9 '$nt o5 th$ ESPEN )ui,$lin$% on Ent$ral Nutrition# Clin Nutr 2006A25(2)!20F-9# 56# Loch% 7, Alli%on SP, -$i$r R, Pirlich -, 4on,ru 3, Schn$i,$r St, &an ,$n =$r0h$ ), Pichar, C# Intro,uctor; to th$ ESPEN )ui,$lin$% on Ent$ral Nutrition! T$r'inolo0;, +$5inition% an, )$n$ral To ic%# Clin Nutr 2006A25(2)!@80-6#