Edema is fluid accumulation in the extremities, legs and feet. Albumin is a protein that is made in the liver. One of its roles is to help regulate the positioning of body water. In liver cirrhosis there is decreased production of albumin, one of the consequences is that water moves out into what is called the "third space", thus the swelling or edema. Edema and ascites both respond to sodium restriction and water pills. The liver influences on nutrition include the metabolism of carbohydrates, fats, and protein. This is the storage place for fat-soluble vitamins A, D, E and K. Dietary protein is likely to be an issue for some people with cirrhosis. The reason is that the liver is central to protein metabolism. The liver also functions in detoxification of waste products. Protein wastes can be particularly toxic if they are not converted to a form that can be easily removed from the body. Certain proteins (vegetables and dairy) are less toxic than others (meat). Hepatic encephalopathy (a long name for confusion) is one problem people with cirrhosis (especially extensive liver damage) might experience. You may be asked to limit protein because it is one of those toxic byproducts (ammonia) of abnormal protein metabolism that is involved in this confusion. Most people think that the vegetable and dairy protein is better tolerated and you might be able to have a lot more of this type than meat protein. There is a drug called Lactulose that is used routinely to rid the body of ammonia. It is used to allow patients more leverage with their diet. One of the problems with this is that diarrhea is the mechanism of action. Accumulation of fat in the liver cells interferes with normal function and ultimately causes them to die. Therefore, a diet modified in fat is suggested. We normally recommend about 30% for cirrhosis; I suggest around 20-25%. Fried foods, whole fat dairy and excess table fats should be avoided. If you need extra calories, medium chain triglycerides (MCTS-designer fats) can be substituted for the usual table fats. If you follow a very low fat diet or decide on the MCTs, you may need to supplement with essential fatty acids (EFA e.g. evening primrose oil) to prevent an EFA deficiency. Carbohydrate metabolism can be deranged too. Hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) can happen as a result. The recommendation is for high complex carbohydrates (avoid excess simple carbohydrates like sugar, syrups, jellies, regular sodas and sweet desserts). Stick with bread, pasta, rice and cereals. Whole grains are always better than white flour products. With cirrhosis, as with any chronic disease, a multivitamin with mineral supplement is always recommended. B vitamin deficiency is common and a good B complex vitamin is usually a good idea. The multivitamin with mineral and B complex is pretty safe, however, your MD should prescribe supplements and you should be monitored closely, as the liver is no longer capable of detoxifying. Too much of any single nutrient might be toxic. This is a very complex disease with multiple complications as you can see, and this is only from a nutrition standpoint.

Do you recommend the over-the-counter liver detoxifiers? Among those I have seen for sale are Milk Thistle (Silymarin), Alpha Lipoic Acid/Sustain, and Glycyrrhizinate Forte. How do these work, when, if ever, are they recommended and at what dosages? (January, 1999)

Answer: Diana Peabody, RD responds: Milk Thistle (Silybum marianum): Active component is Silymarin. The highest concentration is in the fruit of the plant. Known to be effective in preventing liver damage and enhancing liver function and may be particularly helpful when taking liver-toxic medications or to treat cirrhosis or hepatitis. Dosage recommendations vary as does the potency of the pills. A reasonable dose seems to be 140-150 mg Silymarin taken 3 times a day.

Alpha Lipoic Acid: Most studies use a dose of 600 mg per day, which is expensive. Alpha Lipoic Acid has been used to detoxify the liver in Europe for some time. It is also a powerful antioxidant and has a role in the regeneration of glutathione. Alpha Lipoic Acid has been shown to inhibit HIV replication via the NFKB pathway in test tube studies. It has also been shown to have a potential role in treatment of insulin resistance and diabetes induced peripheral neuropathy.

Glycyrrhizin: At 150-225 mg per day, it may have benefit to the immune system as well as liver function. NAC may improve the action of glycyrrhizin on the liver. Of note is that high doses of glycyrrhizin can cause sodium and water retention and high blood pressure. It should be used cautiously by people with a history of high blood pressure.

Other potential liver detoxifiers are curcumin (the active ingredient in turmeric) and dandelion. Dosage depends on the form the compound comes in.

Don't forget to eat well and consider other supplements as suggested by Charlie on his liver sheet. See Q&A on Lipodystrophy.

Question #5: Juicing (and other potential remedies)
What are some of the best foods to juice to cleanse the liver? Beets and parsley were recently recommended to me. (April, 1999)

Answer: Diana Peabody, RD responds: I don't have much information about juice but here are some liver healing foods from a Traditional Chinese Medicine & AIDS book:

1. One ounce of beets per day;
2. Make tea of 2 crushed plums and drink daily;
3. Simmer 15 grams of bitter vegetable (Ku Mai Cai) in water and take 2 per day;
4. Simmer 30 grams of watershield (Chun Cai) in water. Use entire plant. Add pinch of sugar and take 2 per day.

Also, don't forget dandelion, Milk Thistle and curcumin for herbs as discussed above.