Two randomized controlled studies comparing the nutritional benefits of branched-chain amino acid (BCAA) granules and a BCAA-enriched nutrient mixture for patients with esophageal varices after endoscopic treatment
Yoshiyuki Sakai
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Yoshinori Iwata
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Hirayuki Enomoto
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Masaki Saito
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Kazunori Yoh
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Akio Ishii
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Tomoyuki Takashima
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Nobuhiro Aizawa
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Naoto Ikeda
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Hironori Tanaka
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Hiroko Iijima
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Shuhei Nishiguchi
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Y. Sakai Y. Iwata H. Enomoto (&) M. Saito K. Yoh A. Ishii T. Takashima N. Aizawa N. Ikeda H. Tanaka H. Iijima S. Nishiguchi Division of Hepatobiliary and Pancreatic Disease, Department of Internal Medicine, Hyogo College of Medicine
, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501,
Japan
Background The usefulness of branched-chain amino acid (BCAA) granules and BCAA-enriched nutrient mixtures for patients with liver cirrhosis is often reported. However, no randomized controlled studies have investigated the usefulness of these supplements in the nutritional intervention of cirrhotic patients receiving endoscopic treatment for esophageal varices. Methods Patients without BCAA before endoscopic treatment were divided into study 1, and those who received BCAA were divided into study 2. In study 1, 44 eligible patients were divided into a control group (n = 13), a general liquid nutrient (snack) group (n = 15), and a BCAA-enriched nutrient mixture (BCAA-EN) group (n = 16). In study 2, 48 eligible patients were divided into a BCAA group (n = 24) and a BCAA-EN group (n = 24). The nutritional status including non-protein respiratory quotient (NPRQ) levels, weight gain, and albumin were evaluated on days 0, 7, and 50. Results In study 1, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 as compared with the snack group. In study 2, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 and in weight levels on day 50 relative to the BCAA group, while the BCAA group showed improved serum albumin levels on day 7 compared to the BCAA-EN group. Conclusions The BCAA-enriched nutrient mixture maintained NPRQ and weight in cirrhotic patients. Our findings suggest that supplements including both BCAA and a nutritional energy supplement would be beneficial for cirrhotic patients undergoing endoscopic treatment for esophageal varices.
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Esophageal and gastric varices are common adverse events
associated with portal hypertension in cirrhotic patients [1].
Indeed, at the time of diagnosis, 60 % of patients already
have esophageal varices of different grades. These varices
gradually become larger and eventually start bleeding.
Because the acute bleeding is a life-threatening medical
emergency, it constitutes a turning point in the severity of
the portal hypertension. Additionally, most cirrhotic
patients suffer from severe protein energy malnutrition
(PEM) [24], which has been identified as a predictor of
liver cirrhosis adverse events [5].
The nutritional status of cirrhotic patients is even more
problematic during treatments for esophageal and gastric
varices. In Japan, endoscopic injection sclerotherapy and
esophageal variceal ligation are established not only for
hemostasis during hematemesis from the esophageal
varices, but also as prophylactic treatments [68]. However,
because dietary intake during these treatments is restricted,
there is a high possibility of worsening cirrhotic PEM
during the fasting period following treatment [911].
Nagata et al. [11] reported that a significant decrease in
body weight occurred during the treatment of esophageal
varices, and that the decreased body weight failed to
recover after three months. It is thought that malnutrition is
prolonged over a long period of time after treatment.
Hence, nutritional therapeutic intervention is necessary to
maintain and improve nutritional status and hepatic spare
ability during treatment of esophageal varices.
For patients with liver cirrhosis, BCAA is reported to
offer various benefits: improved hypoalbuminemia [12
15], suppressive effects on the occurrence of adverse
events from cirrhosis of the liver [10], suppressive
effects on liver cancer [16, 17], and remedial effects on
insulin resistance [18, 19]. Additionally, the usefulness
of late-evening snacks (LES) is becoming clear [2022].
However, studies that have found nutritional
intervention to be useful after the treatment of esophageal
varices are few. Further, there are no previous reports on
either prospective controlled studies that included a
control group that did not receive nutritional
intervention, or on controlled studies that targeted cases where
BCAA was introduced. We performed here two
different studies to examine the optimal nutritional
replenishment therapy for maintaining and improving the
nutritional status of patients receiving treatment for
esophageal varices.
This study was conducted by placing patients who were not
receiving BCAA during the treatment of esophageal
varices into study 1, and patients who had already received a
BCAA preparation for at least a month during treatment
into study 2 (Fig. 1a), since nutritional therapy with BCAA
could have represented a biasing factor. Endoscopic
treatment of the esophageal varices w (...truncated)