Malnutrition is one of the most common complications associated with cirrhosis and is diagnosed in anywhere from 5% to 99% of patients depending upon the assessment methods that are used. Malnutrition is associated with increased risk of mortality, higher prevalence of portal hypertension–related complications and infections, as well as longer stays in hospital. In mixed populations of malnourished patients, the benefits of nutrition therapy are evidenced by reductions in mortality, infections, systemic inflammatory responses, and hospital length of stay.

Nutrition screening and assessment are performed infrequently in patients with cirrhosis due to the absence of a validated “rapid” screening tool, multiple definitions of what constitutes malnutrition, and challenges with interpreting body composition and laboratory results in the setting of volume overload and liver dysfunction.

“Malnutrition” can refer to a state of either undernutrition or overnutrition. To this review, “malnutrition” will be used synonymously with “undernutrition.” Malnutrition is diagnosed following a comprehensive nutritional assessment. Multiple methods have been applied to evaluate malnutrition (e.g., Subjective Global Assessment [SGA], anthropometry (weight/BMI, mid arm circumference, skin fold thickness), nutritional index, dual X-ray absorptiometry, computed tomography [CT]/magnetic resonance imaging [MRI]), which has led to divergent results. The depletion of muscle mass (commonly termed “sarcopenia”) has emerged as the “central core” of the nutrition assessment in cirrhosis.

The etiology of malnutrition in cirrhosis involves multiple processes resulting from combined disturbances of oral intake, absorption, and metabolism of nutrients. First, impaired dietary intake is a principal cause of malnutrition and may arise because of gastrointestinal symptoms, anorexia (lack of appetite, dysgeusia (distaste), and prescription of unpalatable diets. Second, nutrient malabsorption may occur in patients with cirrhosis due to multiple factors, the mechanisms for which are incompletely understood. Third, altered macronutrient metabolism is a cornerstone mechanism contributing to malnutrition in cirrhosis.

In conclusion, malnutrition prevalence was still considerable even in the obesity era. malnutrition in cirrhosis is multifactorial. Treating malnutrition requires a comprehensive and multidisciplinary strategy and surveillance.

Nutrition therapy for malnutrition key elements

· Assessment of dietary intake by trained personnel (ideally by a provider/dietician with knowledge of managing patients with liver disease) working as part of a team with the hepatologist. Assessment should include quality and quantity of food and supplements, fluids, sodium in diet, number, and timing of meals during the day and barriers for eating.

· Start nutritional counselling by a multidisciplinary team supporting the patient for adequate calories and protein intake in patients with malnutrition and cirrhosis.

· Optimal daily energy intake should not be lower than the recommended 35 kcal/kg actual body weight

· Optimal daily protein intake should not be lower than the recommended 1.5 g/kg actual body weight

· Include late evening oral nutritional supplementation (ONS) and breakfast containing some proteins in malnourished decompensated cirrhotic patients

· BCAA supplements and leucine enriched amino acid supplements should be considered in decompensated cirrhotic patients

· 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

· Avoid hypomobility in cirrhotic patients and propose a personalized physical activity program even in decompensated patients whenever possible

· Implement a nutritional and lifestyle program to achieve a progressive weight loss (> 5–10%) in obese cirrhotic patients (BMI >30 kg/m2 corrected for water retention)

· Adopt a tailored, moderately hypocaloric (-500–800 kcal/day) diet, including an adequate amount of protein (>1.5 g protein/kg BW/day) to achieve weight loss without compromising protein stores in obese cirrhotic patients

· In cirrhotic patients, administer micronutrients and vitamins to treat confirmed or clinically suspected deficiency

· Supplement vitamin D orally in cirrhotic patients with vitamin D levels <20 ng/ml, to reach serum vitamin D (25(OH)D) >30 ng/ml

· In cirrhotic patients with ascites following sodium restriction (recommended intake of sodium ~80 mmol day = 2 g of sodium

· Virtually no food other than alcohol damages the liver and/or is genuinely contraindicated in patients with chronic liver disease

· In most patients with chronic liver disease, eating an adequate number of calories and protein is much more important than avoiding specific types of food, so it is important that you have a good, varied diet that you enjoy

· You should try to split your food intake into three main meals (breakfast, lunch and dinner) and three snacks (mid-morning, mid-afternoon, late evening). The late-evening snack is the most important, as it covers the long interval between dinner and breakfast

· You should try to eat as many fruits and vegetables as you can. If you feel that this makes you feel bloated, and that it makes you eat less, please report to your doctor or dietician

· You should try not to add too much salt to your food. It may take some time to adjust, but it usually gets easier with time. However, if you keep feeling that this makes your food unpleasant to eat, and that it makes you eat less, please report to your doctor or dietician

· Supplement dietary intake by enteral nutrition in critically ill cirrhotic patients who are unable to achieve adequate diet by mouth. If oral diet or enteral nutrition are not tolerated or contra-indicated, consider parenteral nutrition

· Avoid PEG insertion in cirrhotic patients due to risk of bleeding

· Take care that daily energy intake in critically ill cirrhotic patients is not lower than the recommended 35–40 kcal kg-1 d-1 or 1.3 times measured resting energy expenditure