Journal of Gastroenterology and Hepatology (2000) 15, 1436–1441 chronic liver disorders, the more severe the malnutri- tion, the worse the prognosis. 2–6 Moreover, protein depletion in patients with cirrhosis is correlated with the severity of the liver disease. 7 Severe protein malnu- trition in these patients favours immune incompet- ence, 8 infections and exacerbates hypoalbuminemia and ascites. Similarly, patients with cirrhosis suffer from downregulation of the gluconeogenic pathways and decreased insulin metabolism, and are thus at risk of developing hypoglycemia. 9,10 Disturbances of protein and carbohydrate metabolism are therefore the most relevant for, and responsive to, nutritional supplemen- tation. Nutritional supplements have been found to INTRODUCTION The liver is the site of a large number of biochemical pathways responsible for the production and utilization of nutrients. It has a central role in carbohydrate, lipid and nitrogen metabolism, and is one of the key organs incorporating nutrients into the lean body mass of skeleton and muscle. Therefore, chronic liver disease has major nutritional and metabolic implications. Severe protein caloric malnutrition is common in patients with advanced chronic liver disorders, 1 and seriously undermines the liver’s capacity for regenera- tion and functional restoration. For patients with CASE REPORT A balanced 5:1 carbohydrate : protein diet: A new method for supplementing protein to patients with chronic liver disease YARON ILAN,* TAMAR SOBOL, † ODELIA SASSON,* YAFA ASHUR* AND ELLIOT M BERRY † *Liver Unit, Department of Medicine and † Department of Human Nutrition and Metabolism, Hadassah Hebrew-University Medical School, Jerusalem, Israel Abstract Background and Aims: Protein malnutrition in patients with chronic liver disease contributes to bone and muscle weakness and compromises immune function and survival. In contrast, high-protein diets may induce or exacerbate hepatic encephalopathy. The aim of the present study was to test whether increased amounts of protein, balanced by dietary carbohydrate in a 1:5 ratio, may be given to chronic liver disease patients in order to minimize postprandial increases in plasma amino acid (AA) concentrations. Methods: Eight patients with chronic liver disease were studied. Each received, in a randomized order, three different diets of 2510 kJ of either high protein (37:50:28, carbohydrate : protein : fat), high car- bohydrate (126:10:6) or a balanced 5:1 carbohydrate : protein diet (105:21:11). All patients were fol- lowed for plasma AA, glucose and insulin levels, as well as for cognitive and behavioral changes. Results: Following the high protein diet, AA concentrations were significantly increased. In contrast, after the balanced diet, AA levels were practically constant enabled. All diets was well tolerated and no cognitive or behavioral changes appeared. Conclusion:The administration of a balanced 5:1 carbohydrate : protein diet may enable patients with chronic liver disease to tolerate increased amounts of dietary protein, without altering plasma amino acid concentrations. © 2000 Blackwell Science Asia Pty Ltd Key words: aromatic amino acids, branched chain amino acids, chronic liver disease, dietary protein, nutrition. Correspondence: Dr Y Ilan, Liver Unit, Department of Medicine, Hadassah University Hospital, P.O.B 12000, Jerusalem IL-91120, Israel. ilan@hadassah.org.il Accepted for publication 3 March 2000.