Clinical Practice Guidelines

Nutrition in chronic
liver disease
 Malnutrition definition

• The term “malnutrition” can refer both to deficiencies and to excesses in nutritional status
– However, in the present guideline, “malnutrition” is used as a synonym of “undernutrition” only

• In addition to cirrhotic patients with undernutrition, overweight or obese patients with cirrhosis are
increasingly being seen, due to the increased number of cirrhosis cases related to NASH
– Muscle mass depletion may also occur in these patients, but due to the coexistence of obesity,
sarcopenia might be overlooked

• Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with cirrhosis

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Prevalence and implications of malnutrition and sarcopenia in cirrhosis

• Malnutrition is a frequent burden in cirrhosis

– In 20% of patients with compensated cirrhosis
– In >50% of patients with decompensated cirrhosis 1

• Progression of malnutrition is associated with progression of liver failure

– May be less evident in compensated cirrhosis
– Easily recognizable in patients with decompensated cirrhosis

• Both adipose tissue and muscle tissue can be depleted

– In female patients, depletion of fat deposits is more frequent
– In men, loss of muscle tissue is more rapid 1,2

1. Italian multicentre cooperative project on nutrition in liver cirrhosis. J Hepatol 1994;21:317–25;

2. Caregaro L, et al. Am J Clin Nutr 1996;63:602–9
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Prevalence and implications of malnutrition and sarcopenia in cirrhosis

• Malnutrition and muscle mass loss (sarcopenia), which is often used as an equivalent of severe
malnutrition,1 associate with complications:2
– Susceptibility to infections
– Hepatic encephalopathy
– Ascites
– Independent predictors of lower survival in cirrhosis and in patients undergoing liver transplantation

• Malnutrition and sarcopenia should be recognized as complications of cirrhosis that worsen the
prognosis of patients
– General agreement that these patients’ dietary intake needs to improve
– Whether malnutrition can be reversed in patients with cirrhosis is unclear

1. Dasarathy S, et al. J Cachexia Sarcopenia Muscle 2012;3:225–37;

2. Huisman EJ, et al. Eur J Gastroenterol Hepatol 2011;23:982–9
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Relationship between malnutrition, complications of cirrhosis,
transplantation, and survival

Decompensated Malnutrition and/or

cirrhosis sarcopenia

Hepatic encephalopathy
Bacterial infections
Recurrent ascites

Reduced overall survival

• In HCC: increased complications and reduced survival
• After surgery: reduced survival
• In liver transplantation: increased waiting list mortality and post-operative complications
Tandon P, et al. Hepatology 2017;65:1044–5
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Screening for malnutrition in cirrhosis

• As malnutrition is associated with worse prognosis, all patients with advanced chronic liver
disease, especially decompensated cirrhosis, should undergo a rapid nutritional screen
• Two criteria stratify patients at high risk of malnutrition:
– Being underweight (BMI <18.5 kg/m2)
– Advanced decompensated cirrhosis (Child–Pugh C)

Recommendations Grade of evidence Grade of recommendation

Perform a rapid nutritional screen in all patients with cirrhosis and complete a detailed assessment
II-2 B 1
in those at risk of malnutrition to confirm the presence and severity of malnutrition
Assume malnutrition risk is high if BMI <18.5 kg/m2 or Child–Pugh C. In all other cases, utilize
II-2 B 1
nutritional screening tools to assess risk of malnutrition

• All patients at risk of malnutrition should undergo detailed nutritional assessment by a registered
dietician or nutrition expert

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Detailed nutritional assessment

• In patients at high risk of malnutrition, assess each component every 1–6 months in the
outpatient setting and for inpatients, at admission and periodically throughout the hospital stay:1
– Muscle mass and sarcopenia
• Direct quantification of skeletal muscle mass via CT image analysis at the L3 vertebra (only when CT is available
as being performed for other reasons)
• Body mass assessment via anthropometric methods*
• Bone mineral density, fat mass and fat-free mass via DEXA
• Limb non-fat mass quantification via tetrapolar BIA
• Sarcopenia indicated by impaired skeletal muscle contractile function; via handgrip strength
– Subjective global assessment (SGA) uses clinical evaluation data to determine nutritional status without
objective measurements
• Includes the Royal Free Hospital-global assessment (RFH-GA)2
– Patient-reported dietary intake

*Including mid-arm muscle circumference (MAMC), mid-arm muscular area (MAMA) and triceps skinfold (TSF)
1. Tandon P, et al. Hepatology 2017;65:1044–57; 2. Morgan MY, et al. Hepatology 2006;44:823–35
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Detailed nutritional assessment

Recommendations Grade of evidence Grade of recommendation

Include an assessment of sarcopenia within the nutritional assessment II-2 B 1
Assess muscle mass by CT imaging where available (having been performed for other purposes).
II-2 B 1
Anthropometry, DEXA or BIA are possible alternatives, which also allow serial measurements
Assess muscle function in the clinical setting with the most appropriate tools, such as handgrip
II-2 B 1
strength (HGS) and/or the short physical performance battery (SPPB)
Assessment of dietary intake by trained personnel (ideally a dietician with knowledge of managing
patients with liver disease) working as part of a team with the hepatologist. Assessment should
II-2 B 1
include: quality and quantity of food and supplements, fluids, sodium in diet, number and timing of
meals during the day and barriers to eating

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional screening and assessment in patients with cirrhosis: Summary

Cirrhosis/advanced chronic liver disease

Calculate Child–Pugh score

Assess whether fluid Estimate dry weight
retention if needed*
Child C Child A or B

Underweight <18.5 kg/m2 BMI ≥30 kg/m2 Obesity

18.5–29.9 kg/m2

Screen for
Nutritional assessment + Consider
malnutrition
Utilize nutritional
lifestyle intervention in
compensated cirrhosis/ACLD
+ assessing
sarcopenia
screening tools

Follow-up re-screen at
High risk Medium risk Low risk
least 1/year

Detailed nutritional assessment (expert dietician)

Assess sarcopenia
• Subjective global assessment (SGA)
• Consider CT scan to measure muscle area at L3
• Royal Free Hospital-global assessment (RFH-GA)
• Consider DEXA or BIA if no fluid retention
• Reported dietary intake

Sarcopenia Malnutrition No malnutrition

Treat: Nutrition supplementation and appropriate follow-up (repeat

assessment every 1–3 months in first year)
*In the case of fluid retention, body weight should be corrected by evaluating the patient’s dry weight by post-paracentesis body weight or weight recorded before fluid retention if available, or by subtracting a
percentage of weight based upon severity of ascites (mild, 5%; moderate, 10%; severe, 15%), with an additional 5% subtracted if bilateral pedal oedema is present.
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional screening and assessment in patients with cirrhosis: Summary

Cirrhosis/advanced chronic liver disease

Calculate Child–Pugh score

Assess whether fluid Estimate dry weight
retention if needed*
Child C Child A or B

Underweight <18.5 kg/m2 BMI ≥30 kg/m2 Obesity

18.5–29.9 kg/m2

Screen for
Nutritional assessment + Consider
malnutrition
Sedentary lifestyle is highly prevalent in patients + with Utilize nutritional
lifestyle intervention in
compensated cirrhosis/ACLD
assessing
sarcopenia
screening tools
cirrhosis and
High risk
might be
Medium risk
seen as a cofactor
Low risk
Follow-up re-screen at
least 1/year

Detailed nutritional assessment (expert dietician)

Assess sarcopenia
• Subjective global assessment (SGA)
• Consider CT scan to measure muscle area at L3
• Royal Free Hospital-global assessment (RFH-GA)
• Consider DEXA or BIA if no fluid retention
• Reported dietary intake

Sarcopenia Malnutrition No malnutrition

Treat: Nutrition supplementation and appropriate follow-up (repeat

assessment every 1–3 months in first year)
*In the case of fluid retention, body weight should be corrected by evaluating the patient’s dry weight by post-paracentesis body weight or weight recorded before fluid retention if available, or by subtracting a
percentage of weight based upon severity of ascites (mild, 5%; moderate, 10%; severe, 15%), with an additional 5% subtracted if bilateral pedal oedema is present.
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional management principles in cirrhosis:
Energy and protein requirements

• Cirrhosis is a state of accelerated starvation characterized by a rapid post-absorptive physiology

and reduced respiratory quotient
– Protein synthesis is decreased and gluconeogenesis from amino acids increased, necessitating
proteolysis, which contributes to sarcopenia
• Energy supply needs to balance total energy expenditure (TEE)
– Most interventions aim for ≥35 kcal/kg.BW/day*

Recommendations Grade of evidence Grade of recommendation

Performance of nutritional counselling in patients with malnutrition and cirrhosis by a
multidisciplinary team to help the patient achieve adequate calorie and protein intake II-2 C 2
Optimal daily energy intake should not be lower than the recommended 35 kcal/kg actual BW/day
(in non-obese individuals) II-2 B 1
Optimal daily protein intake should not be lower than the recommended 1.2–1.5 g/kg actual
body weight/day II-2 B 1
Include late evening oral nutritional supplementation (ONS) and breakfast in the dietary regimen of
malnourished patients with decompensated cirrhosis II-1 B 1

*Use of actual BW corrected for ascites is considered safe

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Practical advice for patients

• Healthy eating of a variety of foods is advisable for all patients

• With the exception of alcohol, virtually no food damages the liver and is genuinely
contraindicated in patients with chronic liver disease
• In most cases eating adequate calories and protein is much more important than avoiding
specific types of food
– It is important that patients have a good, varied diet that they enjoy
• Food intake should be split
– Three main meals: breakfast, lunch and dinner
– Three snacks:
• Mid-morning, mid-afternoon, late evening
• Late-evening snack is the most important

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Practical advice for patients

• Fruit and vegetables should always be included in the diet

• Salt should be restricted

Patients should report reduced food intake as a result of this advice to their doctor or dietician

• Some patients with liver disease may have hepatic encephalopathy

– May tolerate animal proteins less well than vegetable and dairy proteins

Patients should always consult a doctor or dietician before altering their protein intake

• Patients with concomitant disease* may require dietary adjustments

Patients should report any coexisting condition or previous dietary advice

*For example diabetes or obesity

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Practical advice for patients

• As many fruit and vegetables as possible should be eaten

• Salt should be restricted

Patients should report reduced food/protein intake as a result of this advice to their doctor
or dietician

• Some patients with liver disease may have hepatic encephalopathy

A reduction in total protein intake is not advisable
– May tolerate animal proteins less well than vegetable and dairy proteins
in cirrhosis
Patients should always consult a doctor or dietician before altering their protein intake

• Patients with concomitant disease* may require dietary adjustments

Patients should report any coexisting condition or previous dietary advice

*For example diabetes or obesity

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Mechanisms resulting in sarcopenia and failure to respond to
standard supplementation

• Anabolic resistance and dysregulated proteostasis result in sarcopenia and/or failure to respond
to standard supplementation
• These mechanisms represent potential therapeutic targets

Figure adapted from Dasarathy S. Curr Opin Gastroenterol 2016;32:159–65

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Approach to sarcopenia in patients with cirrhosis

• Skeletal muscle mass is the largest protein store in the body

– Depends on age, gender, ethnicity, severity/aetiology of liver disease

• Adequate calorie and protein intake can be difficult to achieve in malnourished patients with
sarcopenia and advanced liver disease
– Limited but consistent data suggest supplemental nutrition improves quality of life if it results in increased
lean body mass1

• Despite potential adverse effects, a combination of resistance and endurance exercise is likely to
be appropriate and beneficial2

1. Maharshi S, et al. Clin Gastroenterol Hepatol 2016;14:454–60; 2. Berzigotti A, et al. Hepatology 2017;65:1293–305
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Potential management approaches to sarcopenia:
Oral supplements

Supplemental calories/
protein/amino acids

Recommendations Grade of evidence Grade of recommendation

In patients with malnutrition and cirrhosis who are unable to achieve adequate dietary intake with
the oral diet (even with oral supplements), a period of enteral nutrition is recommended II-1 B 1

Figure adapted from Dasarathy S. Curr Opin Gastroenterol 2016;32:159–65

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Potential management approaches to sarcopenia:
BCAA supplements and anaplerotic agents

BCAA supplements
Anaplerotic agents

Recommendations Grade of evidence Grade of recommendation

BCAA supplements and leucine-enriched amino acid supplements should be considered in
patients with decompensated cirrhosis when adequate nitrogen intake is not achieved by oral diet II-1 C 1

Figure adapted from Dasarathy S. Curr Opin Gastroenterol 2016;32:159–65

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Potential management approaches to sarcopenia:
Exercise

Structured exercise
programme

Recommendations Grade of evidence Grade of recommendation

Avoid hypomobility in patients with cirrhosis whenever possible, and progressively increase
physical activity to prevent and/or ameliorate sarcopenia II-1 C 2

Figure adapted from Dasarathy S. Curr Opin Gastroenterol 2016;32:159–65

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Potential management approaches to sarcopenia:
Other approaches

Transplantation
Hormone replacement Ammonia-lowering
Aromatase inhibitors therapy

Myostatin
antagonists

Mitoprotective
agents
Antibiotics
Zinc-gut permeability
Figure adapted from Dasarathy S. Curr Opin Gastroenterol 2016;32:159–65
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Obesity in cirrhosis: Assessment and interpretation

• A sedentary lifestyle is highly prevalent in patients with cirrhosis, increasing obesity risk, but
obesity does not rule out malnutrition
– Obesity is present in most cases of NASH-related cirrhosis
– ‘Sarcopenic obesity’ describes loss of skeletal muscle/gain of adipose tissue and is observed in patients
with cirrhosis
• Estimate and treat malnutrition routinely in obese patients with cirrhosis (BMI >30 kg/m2 in
absence of fluid retention)

Recommendations Grade of evidence Grade of recommendation

In the diagnosis of obesity (BMI >30 kg/m2) always consider the confounding effect of fluid
II-2 B 2
retention. Estimate dry body weight, although accuracy is low

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional management principles in cirrhosis:
Approach and management of obesity

• Multiple studies suggest a reduction in body weight improves outcomes in obese patients with
compensated cirrhosis1–3
• Weight loss can be achieved by nutritional therapy and supervised moderate-intensity physical
exercise tailored to the patient’s ability

Recommendations Grade of evidence Grade of recommendation

Implement a nutritional and lifestyle programme to achieve progressive weight loss (≥5–10%) in
obese patients with cirrhosis (BMI >30 kg/m2 corrected for water retention) II-2 C 1
Adopt a tailored, moderately hypocaloric (-500–800 kcal/day) diet, including an adequate amount
of protein (>1.5 g protein/kg ideal BW/day) to achieve weight loss without compromising protein II-1 C 2
stores in obese patients with cirrhosis

1. Zenith L, et al. Clin Gastroenterol Hepatol 2014;12:e1922; 2. Everhart JE, et al. Gastroenterology 2009;137:549–57;
3. Macias-Rodriguez RU, et al. Clin Transl Gastroenterol 2016;7:e180
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 Micronutrients

• Vitamin deficiencies in liver disease are generally related to hepatic dysfunction and
diminished reserves
– Inadequate dietary intake and malabsorption increase with disease severity

Serum 25(OH)D concentrations in patients with cirrhosis,

stratified by Child–Pugh score in four individual studies1–4

A
Child–Pugh score

B
Crawford, et al.1
Fisher, et al.2
C Chen, et al.3
Putz-Bankuti, et al.4

0 10 20 30 40
Vitamin D (ng/ml)

1. Crawford BAL, et al. Osteoporos Int 2003;14:987–94; 2. Fisher L, et al. Clin Gastroenterol Hepatol 2007;5:513–20;
3. Chen CC, et al. J Gastroenterol Hepatol 1996;11:417–21; 4. Putz-Bankuti C, et al. Liver Int 2012;32:845–51
EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Micronutrients

• A majority of liver disease patients considered for liver transplantation present with vitamin A
and D deficiencies
– Vitamin D levels <20 ng/ml are reported in chronic cholestatic conditions, and often inversely correlate
with disease severity and Child–Pugh score
– Vitamin D also correlates with treatment response in HCV, NAFLD and patients who develop HCC

Recommendations Grade of evidence Grade of recommendation

In patients with cirrhosis, administer micronutrients and vitamins to treat confirmed or clinically
suspected deficiency II-1 C 1
Assess vitamin D levels in patients with cirrhosis as deficiency is highly prevalent and may
adversely affect clinical outcomes II-3 B 1
Supplement vitamin D orally in patients with cirrhosis and vitamin D levels <20 ng/ml, to reach
serum vitamin D (25(OH)D) >30 ng/ml II-1 B 1

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Micronutrients

• Hyponatraemia is common in patients with cirrhosis, and more likely when sodium intake is low
with water unchanged or increased. Careful monitoring of sodium and water intake is required
• Confirmed or clinically suspected micronutrient deficiencies should be treated based on accepted
general recommendations and common practice

Recommendations Grade of evidence Grade of recommendation

In patients with cirrhosis and ascites under sodium restriction (recommended intake of sodium
~80 mmol day = 2 g of sodium corresponding to 5 g of salt added daily to the diet according to
II-2 B 1
EASL guidelines) take care to improve diet palatability as this may cause a reduction in
calorie intake

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional treatment options for hepatic encephalopathy (HE)

• HE is more common in malnourished patients with cirrhosis

– Inverse relationship between muscle mass and blood ammonia levels
• Hyperammonaemia may impair muscle function and contribute to muscle loss 1
• Patients with cirrhosis and HE have the same energy requirements as those without HE
• Although dysregulated nitrogen metabolism plays a key role in HE development, nitrogen requirements
are the same as patients without HE

Recommendations Grade of evidence Grade of recommendation

Nutritional status and sarcopenia should be evaluated in patients with HE II-3 B 1
Avoid protein restriction in patients with HE II-1 A 1
Optimal daily protein and energy intake should not be lower than the general recommendations for
II-1 A 1
patients with cirrhosis
Encourage the consumption of vegetables and dairy protein II-3 B 1
BCAA supplementation should be considered to improve neuropsychiatric performance and to
I-1 A 1
reach the recommended nitrogen intake
Oral dietary intake is preferred in patients who can tolerate it. In patients with grade III–IV
encephalopathy who are unable to eat, provide nutrition by nasogastric tube (in patients with II-1 B 1
protected airways) or parenterally

1. McDaniel J, et al. Am J Physiol Gastrointest Liver Physiol 2016;310:G163–70

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 Nutritional treatment options in patients with cirrhosis
and bone disease – risk factors

• ~30% patients with chronic liver disease, and 30% eligible for liver transplantation have
osteoporosis, with higher prevalence in cholestasis
– Characterized by loss of bone mass and quality, causing fragility fractures

Risk factors for osteoporosis in chronic liver disease

Male hypogonadism Family history of

osteoporotic fracture
Alcohol abuse Treatment with
corticosteroids*
Smoking
Advanced age
BMI <19 kg/m2
Secondary amenorrhoea
Early menopause >6 months

*≥5 mg/d prednisone for ≥3 months

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional treatment options in patients with cirrhosis
and bone disease – diagnosis

• According to the WHO, bone densitometry of the lumbar spine and hip is the gold standard
for diagnosis of osteoporosis and osteopenia
– Should be evaluated in:
• Patients with previous fragility fractures
• Those treated with corticosteroids
• Before liver transplantation
• In cholestatic diseases
• Patients with cirrhosis
• If any other risk factors are found

Recommendations Grade of evidence Grade of recommendation

Evaluate BMD in patients with cirrhosis, cholestatic liver disease, receiving long-term corticosteroid
II-2 A 1
treatment, and before liver transplantation
Utilize lumbar and femoral densitometry (DEXA) for diagnosing osteoporosis and osteopenia.
II-3 A 1
Use lateral X-rays of dorsal and lumbar spine for diagnosing vertebral fractures
Repeat DEXA after 2–3 years in patients within normal BMD, and within 1 year when rapid bone
II-1 B 1
loss is expected

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Nutritional treatment options in patients with cirrhosis
and bone disease – treatment

• A balanced diet is recommended

– Including calcium and 25(OH)D supplements to preserve normal levels
• Physical activity is recommended
– Especially exercises to improve mechanics of the spine
• Factors that increase bone loss (alcohol, tobacco, corticosteroids etc.) should be minimized
• Although studies are limited, bisphosphonates* are reported to increase bone mass in patients with PBC
with no serious adverse events1,2

Recommendations Grade of evidence Grade of recommendation

Include supplements of calcium (1,000–1,500 mg/day) and 25(OH)D (400–800 IU/day or 260 µg
II-3 A 1
every 2 weeks) in patients with chronic liver disease and a T-score below -1.5
Utilize bisphosphonates in patients with cirrhosis and osteoporosis, and in those waiting for
IA 1
liver transplantation
Consider testosterone supplementation and venesection in males with haemochromatosis
II-2 B 1
and hypogonadism

*Including etidronate, alendronate, and ibandronate

1. Guanabens N, et al. Am J Gastroenterol 2003;98:2268–74; 2. Guanabens N, et al. Hepatology 2013;58:2070–8
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 Diagnosis and management of bone disease in patients with
chronic liver disease – summary

Diagnosis Management

DEXA Treatment

Bone densitometry (DEXA) Repeat in

of lumbar spine and hip Normal 2–3 years
T-score >-1.5 Ca + 25(OH)D*
Lateral X-rays of dorsal and Repeat in
lumbar spine Osteopenia
1–2 years†
T-score ≤-1.5 and Ca + 25(OH)D*
>-2.5 Bisphosphonates‡
Laboratory measurements
to identify abnormal Repeat in
calcium and vitamin D Osteoporosis 1 year† Ca + 25(OH)D*
metabolism T-score ≤-2.5 Bisphosphonates
New agents

*Calcium (1,000–1,500 mg/d) and 25-hydroxy-vitamin D (400–800 IU/day or 260 μg every 2 weeks) to preserve normal levels;
†According to the severity of liver disease and cholestasis, and in patients taking corticosteroids;
‡Depending on additional risk factors

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Malnutrition in patients undergoing liver surgery
and liver transplantation – preoperative nutrition

• Patients with severe undernutrition* or obesity† undergoing liver surgery have higher risk of
morbidity and mortality
– Waiting list patients are also at risk due to inadequate food or caloric intake
• Liver glycogen is depleted in patients with cirrhosis
– Periods without nutrient intake should be reduced

Recommendations Grade of evidence Grade of recommendation

Screen for malnutrition and sarcopenia in patients with cirrhosis listed for LT or scheduled for
elective surgery. Treat sarcopenia prior to elective surgery, to enable improvement in body protein III B 2
status and clinical outcomes
Screen for sarcopenic obesity with body composition analysis in obese patients with cirrhosis
III C 2
considered for surgery
If treatment goal is maintenance of nutritional status, plan:
• Total energy intake 30 kcal/kg.BW/day and protein intake 1.2 g/kg.BW/day
II-3 B 1
If treatment goal is improvement of nutritional status, plan:
• Total energy intake 35 kcal/kg.BW/day and protein intake 1.5 g/kg.BW/day
Utilize standard nutrition regimens. Specialized regimens (e.g. BCAA-enriched, immune-enhancing
II-1 B 1
diets) have not been shown to improve morbidity or mortality

*BMI <18.5 kg/m2; †BMI >40 kg/m2

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Malnutrition in patients undergoing liver surgery
and liver transplantation – postoperative nutrition

• Versus fluid and electrolytes only, post-operative nutrition decreases:

– Ventilator time
– Length of ICU stay
– Bacterial and viral infections
– Bile duct and other complications

Recommendations Grade of evidence Grade of recommendation

After LT, initiate normal food and/or enteral tube feeding within 12–24 hours, or as soon as
II-2 B 1
possible, to reduce infection rates
When oral or enteral nutrition are not possible, parenteral nutrition should be used over not feeding II-2 B 1
After the acute postoperative phase, provide an energy intake of 35 kcal/kg.BW/day and protein
II-2 C 1
intake of 1.5 g/kg.BW/day
After other surgical procedures, manage patients with chronic liver disease according to
III C 2
ERAS protocols
Consider parenteral nutrition in patients with unprotected airways and HE when cough and swallow
II-2 C 1
reflexes are compromised, or enteral nutrition is contraindicated or impractical

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Malnutrition in patients undergoing liver surgery
and liver transplantation – postoperative nutrition

• Patients remain in negative nitrogen balance after LT

– Necessitates an increase in protein or amino acid provision
– Nutrition improves nitrogen economy in non-transplant visceral surgery
• Chronic dilutional hyponatraemia should be carefully corrected after LT to avoid
pontine myelinolysis
• Long-term LT survivors risk weight gain/obesity due to metabolic syndrome
– Stringent physiotherapy and dietary counselling should be used

Recommendations Grade of evidence Grade of recommendation

In obese patients, utilize enteral tube feeding and/or parenteral nutrition with a reduced target
energy intake (25 kcal/kg ideal BW*/day) and an increased target protein intake III C 2
(2.0 g/kg ideal BW*/day)

*Ideal body weight as calculated based on height and gender

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Malnutrition in critically ill patients with cirrhosis

• Critically ill patients include those:

– Hospitalized for severe complications of chronic liver disease
– With acute-on-chronic liver failure
– In an ICU
– With acute alcoholic hepatitis

Recommendations Grade of evidence Grade of recommendation

Consider nutritional status and presence of sarcopenia. Provide nutritional support while treating
II-3 C 1
other manifestations of severe decompensation
Daily energy intake should not be lower than 35–40 kcal/kg.BW/day, or 1.3x measured REE II-2 B 1
Daily protein intake should not be lower than 1.2–1.3 g/kg.BW/day II-2 B 1

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Malnutrition in critically ill patients with cirrhosis

• Direct measurement of REE by indirect calorimetry is advisable

• As in all critically ill patients, tight glucose control is indicated
• Enteral or parenteral nutrition is more likely to be required

Recommendations Grade of evidence Grade of recommendation

Supplement dietary intake by enteral nutrition in patients unable to achieve adequate intake
by mouth. If oral diet or enteral nutrition are not tolerated or contraindicated, provide III A 1
parenteral nutrition
Utilize standard nutrition regimens. Specialized regimens (e.g. BCAA-enriched, immune-enhancing
II-1 B 2
diets) have not been shown to improve morbidity or mortality
In patients with HE, consider BCAA-enriched solutions IA 1

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024
 Malnutrition and other special considerations

Alcoholic liver disease and severe/acute alcoholic hepatitis

• Patients with active alcohol abuse may have a higher REE

Gastrointestinal bleeding
• Withhold enteral nutrition for 48–72 hours after acute bleeding due to risk of increased portal
pressure and variceal re-bleeding

Recommendations Grade of evidence Grade of recommendation

Naso-gastroenteric tubes are not contraindicated in patients with non-bleeding
II-2 A 1
oesophageal varices
Avoid PEG insertion in patients with cirrhosis due to risk of bleeding III B 2
In cirrhosis and severe/acute alcoholic hepatitis, provide nutritional support as it may accelerate
II-1 A 1
resolution of hepatic encephalopathy and improve survival in patients with low calorie intake

EASL CPG nutrition in chronic liver disease. J Hepatol 2018; doi: 10.1016/j.jhep.2018.06.024