Hepatic encephalopathy (HE) is an incompletely understood
phenomenon and serves as a poor prognosis in patients with
cirrhosis. Confusion from HE can affect the ability to eat
adequately. Despite the prevalence of malnutrition in cirrhotic
patients in the 1950s, it was reported that bouts of overt HE
were controlled with low protein intake. This largely
uncontrolled observation led to restriction of protein intake in
cirrhotic patients with or without HE and was an accepted
standard of care for many decades to follow. Published in 2004,
the pivotal article "Normal Protein Diet for Episodic Hepatic
Encephalopathy: Results of a Randomized Study" by Cordoba and
colleagues was the first controlled study randomizing cirrhotic
patients with HE to receive different amounts of dietary
protein. At the completion of the study, the authors concluded
that a normal-protein diet was safe and did not exacerbate HE.
The Cordoba study suggests that low-protein diets should be
abandoned. In light of this evidence, nutrition gu