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Cochrane Database of Systematic Reviews
Nutritional support for liver disease (Review)
Koretz RL, Avenell A, Lipman TO
Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD008344. DOI: 10.1002/14651858.CD008344.pub2.
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Nutritional support for liver disease (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Library
Trusted evidence. Informed decisions. Better health.
Cochrane Database of Systematic Reviews
T A B L E O F C O N T E N T S HEADER………………………………………………………………………………………………………………………………………………………………………………… 1 ABSTRACT…………………………………………………………………………………………………………………………………………………………………………….. 1 PLAIN LANGUAGE SUMMARY………………………………………………………………………………………………………………………………………………….. 2 BACKGROUND………………………………………………………………………………………………………………………………………………………………………. 4 OBJECTIVES………………………………………………………………………………………………………………………………………………………………………….. 4 METHODS…………………………………………………………………………………………………………………………………………………………………………….. 5 RESULTS……………………………………………………………………………………………………………………………………………………………………………….. 9
Figure 1………………………………………………………………………………………………………………………………………………………………………….. 10 Figure 2………………………………………………………………………………………………………………………………………………………………………….. 11 Figure 3………………………………………………………………………………………………………………………………………………………………………….. 20
DISCUSSION………………………………………………………………………………………………………………………………………………………………………….. 21 AUTHORS’ CONCLUSIONS……………………………………………………………………………………………………………………………………………………… 22 ACKNOWLEDGEMENTS………………………………………………………………………………………………………………………………………………………….. 22 REFERENCES………………………………………………………………………………………………………………………………………………………………………… 23 CHARACTERISTICS OF STUDIES……………………………………………………………………………………………………………………………………………… 42 DATA AND ANALYSES……………………………………………………………………………………………………………………………………………………………… 94
Analysis 1.1. Comparison 1 Mortality, Outcome 1 All studies……………………………………………………………………………………………… 97 Analysis 1.2. Comparison 1 Mortality, Outcome 2 Parenteral nutrition………………………………………………………………………………… 97 Analysis 1.3. Comparison 1 Mortality, Outcome 3 Enteral nutrition…………………………………………………………………………………….. 98 Analysis 1.4. Comparison 1 Mortality, Outcome 4 Supplements…………………………………………………………………………………………. 99 Analysis 1.5. Comparison 1 Mortality, Outcome 5 Medical trials…………………………………………………………………………………………. 99 Analysis 1.6. Comparison 1 Mortality, Outcome 6 Surgical trials…………………………………………………………………………………………. 100 Analysis 1.7. Comparison 1 Mortality, Outcome 7 Alcoholic hepatitis………………………………………………………………………………….. 101 Analysis 1.8. Comparison 1 Mortality, Outcome 8 Cirrhosis………………………………………………………………………………………………… 102 Analysis 1.9. Comparison 1 Mortality, Outcome 9 HCC………………………………………………………………………………………………………. 103 Analysis 1.10. Comparison 1 Mortality, Outcome 10 Abstracts excluded……………………………………………………………………………… 103 Analysis 1.11. Comparison 1 Mortality, Outcome 11 Surgical trials without transplant patients……………………………………………. 105 Analysis 1.12. Comparison 1 Mortality, Outcome 12 Intent to treat – best-case scenario for intervention……………………………….. 105 Analysis 1.13. Comparison 1 Mortality, Outcome 13 Intent to treat – worst-case scenario for intervention……………………………… 107 Analysis 2.1. Comparison 2 Appearance of ascites, Outcome 1 All studies…………………………………………………………………………… 111 Analysis 2.2. Comparison 2 Appearance of ascites, Outcome 2 Parenteral nutrition…………………………………………………………….. 111 Analysis 2.4. Comparison 2 Appearance of ascites, Outcome 4 Supplements………………………………………………………………………. 112 Analysis 2.5. Comparison 2 Appearance of ascites, Outcome 5 Medical trials………………………………………………………………………. 112 Analysis 2.6. Comparison 2 Appearance of ascites, Outcome 6 Surgical trials……………………………………………………………………… 113 Analysis 2.7. Comparison 2 Appearance of ascites, Outcome 7 Alcoholic hepatitis………………………………………………………………. 113 Analysis 2.8. Comparison 2 Appearance of ascites, Outcome 8 Cirrhosis…………………………………………………………………………….. 114 Analysis 2.9. Comparison 2 Appearance of ascites, Outcome 9 HCC……………………………………………………………………………………. 115 Analysis 2.10. Comparison 2 Appearance of ascites, Outcome 10 Abstracts excluded…………………………………………………………… 115 Analysis 2.11. Comparison 2 Appearance of ascites, Outcome 11 Surgical trials without transplant………………………………………. 117 Analysis 2.12. Comparison 2 Appearance of ascites, Outcome 12 Intent to treat – best-case scenario for intervention…………….. 117 Analysis 2.13. Comparison 2 Appearance of ascites, Outcome 13 Intent to treat – worst-case scenario for intervention…………… 118 Analysis 3.1. Comparison 3 Resolution of ascites, Outcome 1 All studies…………………………………………………………………………….. 123 Analysis 3.2. Comparison 3 Resolution of ascites, Outcome 2 Parenteral nutrition………………………………………………………………. 123 Analysis 3.3. Comparison 3 Resolution of ascites, Outcome 3 Enteral nutrition…………………………………………………………………… 124 Analysis 3.4. Comparison 3 Resolution of ascites, Outcome 4 Supplements………………………………………………………………………… 124 Analysis 3.5. Comparison 3 Resolution of ascites, Outcome 5 Medical trials………………………………………………………………………… 125 Analysis 3.7. Comparison 3 Resolution of ascites, Outcome 7 Alcoholic hepatitis………………………………………………………………… 125 Analysis 3.8. Comparison 3 Resolution of ascites, Outcome 8 Cirrhosis………………………………………………………………………………. 126 Analysis 3.10. Comparison 3 Resolution of ascites, Outcome 10 Abstracts excluded…………………………………………………………….. 127 Analysis 3.12. Comparison 3 Resolution of ascites, Outcome 12 Intent to treat – best-case scenario for intervention – no changes made because all patients with ascites reported……………………………………………………………………………………………………………….
128
Nutritional support for liver disease (Review) Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Trusted evidence. Informed decisions. Better health.
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Analysis 3.13. Comparison 3 Resolution of ascites, Outcome 13 Intent to treat – worst case scenario for intervention – no changes made because all patients with ascites reported……………………………………………………………………………………………………………….
129
Analysis 4.1. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 1 All studies………………………………………………… 133 Analysis 4.2. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 2 Parenteral nutrition…………………………………… 133 Analysis 4.3. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 3 Enteral nutrition (all medical)…………………….. 134 Analysis 4.4. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 4 Supplements……………………………………………. 134 Analysis 4.5. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 5 Medical trials……………………………………………. 135 Analysis 4.6. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 6 Surgical trials……………………………………………. 136 Analysis 4.7. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 7 Alcoholic hepatitis…………………………………….. 136 Analysis 4.8. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 8 Cirrhosis…………………………………………………… 137 Analysis 4.9. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 9 HCC…………………………………………………………. 138 Analysis 4.10. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 10 Abstracts excluded………………………………… 138 Analysis 4.11. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 11 Surgical trials without transplant patients (no trials with transplant patients)……………………………………………………………………………………………………………………………………
140
Analysis 4.12. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 12 Intent to treat – best-case scenario for intervention…………………………………………………………………………………………………………………………………………………………………….
140
Analysis 4.13. Comparison 4 Appearance of gastrointestinal bleeding, Outcome 13 Intent to treat – worst-case scenario for intervention…………………………………………………………………………………………………………………………………………………………………….
141
Analysis 5.1. Comparison 5 Appearance of encephalopathy – all studies, Outcome 1 All studies……………………………………………. 148 Analysis 5.2. Comparison 5 Appearance of encephalopathy – all studies, Outcome 2 Parenteral nutrition – all trials……………….. 150 Analysis 5.3. Comparison 5 Appearance of encephalopathy – all studies, Outcome 3 Parenteral nutrition – medical trials……….. 150 Analysis 5.4. Comparison 5 Appearance of encephalopathy – all studies, Outcome 4 Parenteral nutrition – surgical trials………… 151 Analysis 5.5. Comparison 5 Appearance of encephalopathy – all studies, Outcome 5 Enteral nutrition – all studies…………………. 151 Analysis 5.6. Comparison 5 Appearance of encephalopathy – all studies, Outcome 6 Enteral nutrition – medical trials…………….. 152 Analysis 5.8. Comparison 5 Appearance of encephalopathy – all studies, Outcome 8 Supplements……………………………………….. 153 Analysis 5.9. Comparison 5 Appearance of encephalopathy – all studies, Outcome 9 Medical trials all trials…………………………… 154 Analysis 5.10. Comparison 5 Appearance of encephalopathy – all studies, Outcome 10 Medical trials – standard amino acids……. 155 Analysis 5.11. Comparison 5 Appearance of encephalopathy – all studies, Outcome 11 Medical trials – BCAAs………………………… 156 Analysis 5.12. Comparison 5 Appearance of encephalopathy – all studies, Outcome 12 Surgical trials – all studies………………….. 157 Analysis 5.14. Comparison 5 Appearance of encephalopathy – all studies, Outcome 14 Surgical trials – BCAAs……………………….. 157 Analysis 5.15. Comparison 5 Appearance of encephalopathy – all studies, Outcome 15 Alcoholic hepatitis – all studies…………… 158 Analysis 5.16. Comparison 5 Appearance of encephalopathy – all studies, Outcome 16 Alcoholic hepatitis – standard amino acids……………………………………………………………………………………………………………………………………………………………………………….
159
Analysis 5.17. Comparison 5 Appearance of encephalopathy – all studies, Outcome 17 Alcoholic hepatitis – BCAA………………….. 160 Analysis 5.18. Comparison 5 Appearance of encephalopathy – all studies, Outcome 18 Cirrhosis – all studies…………………………. 160 Analysis 5.19. Comparison 5 Appearance of encephalopathy – all studies, Outcome 19 Cirrhosis – standard amino acids………… 161 Analysis 5.20. Comparison 5 Appearance of encephalopathy – all studies, Outcome 20 Cirrhosis – BCAAs………………………………. 162 Analysis 5.21. Comparison 5 Appearance of encephalopathy – all studies, Outcome 21 HCC – all studies……………………………….. 163 Analysis 5.23. Comparison 5 Appearance of encephalopathy – all studies, Outcome 23 HCC – BCAAs…………………………………….. 163 Analysis 5.24. Comparison 5 Appearance of encephalopathy – all studies, Outcome 24 Abstracts excluded……………………………. 164 Analysis 5.25. Comparison 5 Appearance of encephalopathy – all studies, Outcome 25 Surgical trials – transplant trials eliminated……………………………………………………………………………………………………………………………………………………………………….
167
Analysis 5.26. Comparison 5 Appearance of encephalopathy – all studies, Outcome 26 ITT – Parenteral nutrition – best-case scenario…………………………………………………………………………………………………………………………………………………………………………..
167
Analysis 5.27. Comparison 5 Appearance of encephalopathy – all studies, Outcome 27 ITT – Parenteral nutrition – worst-case scenario…………………………………………………………………………………………………………………………………………………………………………..
168
Analysis 5.28. Comparison 5 Appearance of encephalopathy – all studies, Outcome 28 ITT – Enteral nutrition – best-case scenario…………………………………………………………………………………………………………………………………………………………………………..
169
Analysis 5.29. Comparison 5 Appearance of encephalopathy – all studies, Outcome 29 ITT – Enteral nutrition – worst-case scenario…………………………………………………………………………………………………………………………………………………………………………..
170
Analysis 5.30. Comparison 5 Appearance of encephalopathy – all studies, Outcome 30 ITT- Supplements – best-case scenario…… 170 Analysis 5.31. Comparison 5 Appearance of encephalopathy – all studies, Outcome 31 ITT – Supplements – worst-case scenario…. 172 Analysis 6.1. Comparison 6 Resolution of encephalopathy, Outcome 1 All trials………………………………………………………………….. 181 Analysis 6.2. Comparison 6 Resolution of encephalopathy, Outcome 2 Parenteral nutrition (all medical trials)………………………. 181
Nutritional support for liver disease (Review) Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ii
Cochrane Library
Trusted evidence. Informed decisions. Better health.
Cochrane Database of Systematic Reviews
Analysis 6.3. Comparison 6 Resolution of encephalopathy, Outcome 3 Enteral nutrition (all medical trials)…………………………… 182 Analysis 6.4. Comparison 6 Resolution of encephalopathy, Outcome 4 Supplements (all medical trials)……………………………….. 182 Analysis 6.5. Comparison 6 Resolution of encephalopathy, Outcome 5 Medical trials – all trials……………………………………………. 183 Analysis 6.6. Comparison 6 Resolution of encephalopathy, Outcome 6 Medical trials – standard amino acids………………………… 184 Analysis 6.7. Comparison 6 Resolution of encephalopathy, Outcome 7 Medical trials – BCAAs………………………………………………. 185 Analysis 6.11. Comparison 6 Resolution of encephalopathy, Outcome 11 Alcoholic hepatitis – all trials…………………………………. 185 Analysis 6.12. Comparison 6 Resolution of encephalopathy, Outcome 12 Alcoholic hepatitis – standard amino acids……………… 186 Analysis 6.13. Comparison 6 Resolution of encephalopathy, Outcome 13 Alcoholic hepatitis – BCAAs…………………………………… 187 Analysis 6.14. Comparison 6 Resolution of encephalopathy, Outcome 14 Cirrhosis – all……………………………………………………….. 187 Analysis 6.16. Comparison 6 Resolution of encephalopathy, Outcome 16 Cirrhosis – BCAAs…………………………………………………. 188 Analysis 6.20. Comparison 6 Resolution of encephalopathy, Outcome 20 Abstracts excluded – all trials………………………………… 188 Analysis 6.21. Comparison 6 Resolution of encephalopathy, Outcome 21 Abstracts excluded – standard amino acids…………….. 189 Analysis 6.22. Comparison 6 Resolution of encephalopathy, Outcome 22 Abstracts excluded – BCAAs…………………………………… 190 Analysis 6.24. Comparison 6 Resolution of encephalopathy, Outcome 24 ITT – All trials – best-case scenario – no changes made because all patients reported…………………………………………………………………………………………………………………………………………..
191
Analysis 6.25. Comparison 6 Resolution of encephalopathy, Outcome 25 ITT – Parenteral nutrition trials – best-case scenario – no changes made because all patients reported……………………………………………………………………………………………………………….
191
Analysis 6.26. Comparison 6 Resolution of encephalopathy, Outcome 26 ITT – Enteral trials – best-case scenario – no changes made because all patients reported………………………………………………………………………………………………………………………………….
192
Analysis 6.27. Comparison 6 Resolution of encephalopathy, Outcome 27 ITT – Supplements trials – best-case scenario – no changes made because all patients reported…………………………………………………………………………………………………………………….
193
Analysis 6.28. Comparison 6 Resolution of encephalopathy, Outcome 28 ITT – All trials – worst-case scenario – no changes made because all patients reported…………………………………………………………………………………………………………………………………………..
193
Analysis 6.29. Comparison 6 Resolution of encephalopathy, Outcome 29 ITT – Parenteral nutrition trials – worst-case scenario – no changes made because all patients reported……………………………………………………………………………………………………………..
194
Analysis 6.30. Comparison 6 Resolution of encephalopathy, Outcome 30 ITT – Enteral nutrition trials – worst-case scenario – no changes made because all patients reported…………………………………………………………………………………………………………………….
195
Analysis 6.31. Comparison 6 Resolution of encephalopathy, Outcome 31 ITT – Supplement trials – worst-case scenario – no changes made because all patients reported…………………………………………………………………………………………………………………….
195
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