Liver disorders in COVID-19, nutritional approaches and the use of phytochemicals

Table 2 Energy and nutrient recommendations for patients with coronavirus disease 2019 with or without liver injury

Energy/Nutrient	Criteria	Recommendation
Estimation of REE	All individuals with COVID-19	Estimation by indirect calorimetry
		Prediction equations
Calories	Normal oral diets	1500-2000 kcals/d
		Increase 400-500 kcals in stress or infection crisis
	Polymorbid, old patients > 65 yr	27 kcals/kg Bw/day
	Low weight, older patients	30 kcals/kg Bw/day
	Malnourish chronic patients and muscle depletion	30-35 kcals/kg Bw/day
	-Patients with COVID-19 outside ICU	ONS with low oral intolerance:
		150-400 kcals/service
		70-100 g protein/service
		Carbohydrates, fiber, PUFAs, vitamins, minerals, probiotics
		Consuming for a month
Protein	Normal individuals (prevent loss and muscle mass)	1 g/kg Bw/day
		70-100 g/d
		Form animal (milk, yogurt, meat, fish, chicken, cheese) and vegetable sources (beans, soy, nuts, peas)
	Patients with liver cirrhosis sarcopenic	1.2-1.5 g/kg Bw/day
	Obese sarcopenic	Oral supplementation of BCAA 0.20-0.25 g/kg Bw/day or 30 g/d
		Glutamine and arginine supplementation
Carbohydrates/fat	Patients with COVID-19 without respiratory impairment	Ratio 70:30 carbohydrates/fat
		Medium and low glycemic
		Fiber 25-30 g/d
		PUFAs: DHA, EPA, ALA
	Patients with ventilator support	Ratio 50:50 carbohydrates/fat
Vitamins	All individuals with COVID-19	A, C, D, E, folate, B6 and B12 (monitoring in patients with liver abnormalities)
Minerals	All individuals with COVID-19	Zinc, copper, selenium (monitoring in patients with liver abnormalities)
	Critically ill patients	EN after 24-36 h. after ICU admission
		Initiate with trophic low-dose (10-20 mL/h.)
		Polymeric formula: 15-20 kcals/kg Bw and 1.2-2.0 g/kg Bw/day of protein vitamins, minerals, fiber, probiotics
		Provide 70%-80% needs in over 1 wk
	Sever obese patients BMI > 50	Energy 22-25 kcals/kg IBW
		Protein 2 g/kg per day (Class I, II) or 2.5 g/kg IBW/day of (Class III)
		Vitamins, minerals, fiber, probiotics
	Gastric intolerance individuals	Use prokinetics
		Post-pyloric feeding in persistence intolerance or at high risk of aspiration
	Patients with no GI feasible	PN recommended
	Poor nutrition status	Limit the use of omega-6 soy-based ILE during first week
	Prolonged stay at ICU	Mixture of lipids such as olive oil based ILE or SMOF (soy, medium chain triglycerides, olive oil, fish oil)

ALA: Alpha linoleic acid; BCAA: Branch chain amino acids; DHA: Docosahexaenoic acid; EN: Enteral nutrition; EPA: Eicosanoid acid; GI: Gastrointestinal; IBW: Ideal body weight; ICU: Intensive care unit; ILE: Intravenous lipid emulsion. ONS: Oral nutritional supplements; PN: Parenteral nutrition; PUFAs: Polyunsaturated fatty acids; REE: Resting energy expenditure.