# Nutritional Support for Liver Diseases
## 2 Nutritional Support for Liver Diseases
### Liver Transplantation
#### 2.4.1 Nutritional Support before Liver Transplantation
[161] also indicates the effectiveness of administering a combination of prebiotics and probiotics to patients before or on the day of transplantation, reducing the frequency of perioperative infections or the duration of prescribed antibiotic therapy [161]. At the same time, the ERAS protocol does not indicate exact recommendations in this area [147]. In the case of preoperative immuno-nutrition (IN), there is no clear evidence to support its use; therefore, IN before liver transplantation is not recommended (evidence level: high; grade of recommendation: weak) [147; 151]. At the same time, there is a study showing that the use of preparations enriched with arginine, omega-3 fatty acids, and nucleotides before the procedure has a positive effect on reducing the frequency of infectious complications and shortening the length of stay after operations in the area of the gastrointestinal tract [153]. \begin{table}
\begin{tabular}{c c c} \hline \hline \multicolumn{2}{c}{**Symptoms/Patient’s Condition**} & \multicolumn{1}{c}{**Recommendation**} \\ \hline \multicolumn{2}{c}{POSTOPERATIVE PERIOD} \\ \hline \multirow{4}{*}{Early period 12–24 h} & \multicolumn{2}{c}{Oral food intake and/or enteral nutrition within 12–24 h} \\  & \multicolumn{2}{c}{after surgery (30–35 kcal/kg/day; \\  & protein: 1.2–1.5 g/kg/day) [147; 155];} \\ \cline{2-3}  & Malnourished patients OR prolonged & \multirow{2}{*}{Additional nutritional support [147; 155];} \\  & postoperative fasting (>5 days) & \\ \cline{2-3}  & Oral route impossible & Parenteral nutrition [147]; \\ \cline{2-3}  & DM risk (immunosuppressive drugs) & Reduce consumption of simple sugars, \\  & & reduce Tacrolimus dose [150]; \\ \cline{2-3}  & Increased potassium level & \\ \cline{2-3}  & (immunosuppressive drugs) & Limit the food products rich in potassium [156]; \\ \cline{2-3}  & Decreased magnesium level & Balanced diet (whole grains, legumes, nuts) [150]; \\ \cline{2-3}  & Excessive body weight (overweight, obesity) & Balanced diet, proper protein intake [150]; \\ \hline \hline \end{tabular}  
* BW—body weight; DM—Diabetes mellitus; EN—enteral nutrition; IBW—ideal body weight; PN—parenteral nutrition; WL—weight loss.  
\end{table} 
Table 2: Cont. Patients preparing for surgery should be careful about the use of any herbs because the compounds contained in them may interact with any medications taken and have hepatotoxic effects [162]. Before the Surgery--ERAS Protocol  
According to the ERAS procedure, the patient's fasting period should be minimized, and the use of protein restrictions in the case of HE is abandoned (recommendation grade GPP, strong consensus 100%) [5]. In patients with hepatic insufficiency, hepatic glycogen is depleted; therefore, it is important to shorten the fasting period of the patient as much as possible. There is no indication that preoperative fasting should exceed 6 h for solid food and 2 h for fluid intake. Thanks to this, the body will not start the process of muscle protein breakdown as a result of ongoing gluconeogenesis and will not deepen the development of sarcopenia. If there are risk factors for late gastric emptying, such as diabetes mellitus, tense ascites, or autonomic dysfunction, care should be taken in preparing the patient [151]. The ERAS protocol assumes that the patient should drink a clear carbohydrate fluid 2 h before surgery. The available literature indicates a beneficial effect of carbohydrate loading before liver surgery on the reduction of postoperative insulin resistance [154]. The beneficial effects of a high-carbohydrate drink were also confirmed in a study by [PERSON] et al. In patients with end-stage liver failure, the administration of the carbohydrate drink helped to improve preoperative nutritional status, reduce infectious complications, and shorten the time of recovery after transplantation. At the same time, the authors of the study noted that the benefits they indicated should be confirmed in a randomized control study [160].