Malnutrition and nutritional screening in patients with cirrhosis

Patients with cirrhosis are often malnourished. Malnutrition can have an impact on hepatic encephalopathy, development of ascites, frailty, incidence of infections and survival in cirrhotic patients. Malnutrition is multifactorial and may be caused by reduced food intake (due to an altered sense of taste, early satiety or lack of appetite), increased energy and protein requirements, and malabsorption.

Protein requirements in patients with cirrhosis are almost double those of a healthy adult. Lack of adequate dietary protein can lead to muscle wasting and sarcopenia, although a decrease in lean body mass may be masked by fluid retention (ie ascites, oedema). It is important to ensure adequate, high-quality nutritional intake.

Note: Protein requirements in patients with cirrhosis are almost double those of a healthy adult.

Nutritional screening is recommended in all patients with cirrhosis. For information about malnutrition screening tools, see Malnutrition in Therapeutic Guidelines: Gastrointestinal. Body mass index (BMI) (corrected for fluid status) and Child–Pugh score can also be used to stratify malnutrition risk—patients with a BMI less than 18.5 kg/m² or Child–Pugh class C cirrhosis are at high risk of malnutrition.

Note: Patients with a BMI less than 18.5 kg/m² or Child–Pugh class C cirrhosis are at high risk of malnutrition.

A patient found to be at risk of malnutrition should be referred to an accredited practising dietitian for assessment and management. Any patient with cirrhosis may benefit from consultation with an accredited practising dietitian to optimise protein and energy intake, and review salt intake.

Obesity can be difficult to manage in patients with cirrhosis. Lifestyle and nutritional interventions are recommended in patients with a BMI of 30 kg/m² or more (using dry weight for patients with ascites and peripheral oedema), aiming for gradual weight loss (5 to 10% over a year). Dietary intervention should be individualised. Dietary intake should be moderately hypocaloric, while preserving protein intake at 1.2 to 1.5 g/kg/day, because obese patients can have malnutrition and sarcopenia. Patients without portal hypertension may be eligible for bariatric surgery. In patients awaiting liver transplant, bariatric surgery may be considered at the time of transplant in some centres, or, more commonly, at 6 to 12 months post-transplant.

For more detailed information, see the EASL Clinical Practice Guidelines on nutrition in chronic liver disease (European Association for the Study of the Liver) [URL].