Nutrition Support of Patients with Cirrhosis



Malnutrition is prevalent among individuals with cirrhosis and has adverse effects on patient outcomes. Prompt attention to assessment of nutrition status to determine cause and degree of malnutrition is the first step in implementing a nutrition plan. Nutrition status can be assessed using a combination of parameters although Subjective Global Assessment is most commonly utilized. CT and MRI scans can also be used to quantify muscle and fat stores but are not frequently used in a clinical setting. Cirrhosis can cause metabolic aberrations affecting the metabolism, storage, and utilization of protein, carbohydrate, and fat. Electrolyte abnormalities and micronutrient deficiencies can ensue and may require supplementation or restriction. Because oral intake is frequently inadequate, nutrition support may be required with enteral nutrition as the preferred option. This chapter provides recommendations for nutrient needs and delivery in patients with cirrhosis considering the symptoms and complications of liver disease.


Cirrhosis Liver disease Malnutrition Nutrition assessment Nutrition status Enteral nutrition Nutrition support 


  1. 1.
    Andus T. ESPEN guidelines on enteral nutrition: liver disease – tube feeding (TF) in patients with esophageal varices is not proven to be safe. Clin Nutr. 2007;26(2):272; author reply 273–4.Google Scholar
  2. 2.
    Baltz JG, Argo CK, Al-Osaimi AM, Northup PG. Mortality after percutaneous endoscopic gastrostomy in patients with cirrhosis: a case series. Gastrointest Endosc. 2010;72(5):1072–5. doi: 10.1016/j.gie.2010.06.043.CrossRefPubMedGoogle Scholar
  3. 3.
    Bémeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological complications. J Clin Exp Hepatol. 2014;4(2):141–50. doi: 10.1016/j.jceh.2013.05.008.CrossRefPubMedGoogle Scholar
  4. 4.
    Córdoba J, López-Hellín J, Planas M, Sabín P, Sanpedro F, Castro F, Esteban R, Guardia J. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. J Hepatol. 2004;41(1):38–43.CrossRefPubMedGoogle Scholar
  5. 5.
    Corey KE, Cohen DE. Lipid and lipoprotein metabolism in liver disease. In: De Groot LJ, Chrousos G, Dungan K, et al. Endotext [Internet]. South Dartmouth (MA):, Inc.; 2000–2015 Jun 27. Available from: Accessed 28 Sept 2016.
  6. 6.
    Crippin JS. Is tube feeding an option in patients with liver disease? Nutr Clin Pract. 2006;21(3):296–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Crook MA. Refeeding syndrome: problems with definition and management. Nutrition. 2014;30(11–12):1448–55. doi: 10.1016/j.nut.2014.03.026.CrossRefPubMedGoogle Scholar
  8. 8.
    Cruz Jr RJ, Dew MA, Myaskovsky L, Goodpaster B, Fox K, Fontes P, DiMartini A. Objective radiologic assessment of body composition in patients with end-stage liver disease: going beyond the BMI. Transplantation. 2013;95(4):617–22. doi: 10.1097/TP.0b013e31827a0f27.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8–13.CrossRefPubMedGoogle Scholar
  10. 10.
    Dreyer HC, Drummond MJ, Pennings B, Fujita S, Glynn EL, Chinkes DL, Dhanani S, Volpi E, Rasmussen BB. Leucine-enriched essential amino acid and carbohydrate ingestion following resistance exercise enhances mTOR signaling and protein synthesis in human muscle. Am J Physiol Endocrinol Metab. 2008;294(2):E392–400.CrossRefPubMedGoogle Scholar
  11. 11.
    Drummond MJ, Rasmussen BB. Leucine-enriched nutrients and the regulation of mammalian target of rapamycin signalling and human skeletal muscle protein synthesis. Curr Opin Clin Nutr Metab Care. 2008;11(3):222–6. doi: 10.1097/MCO.0b013e3282fa17fb.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Englesbe MJ, Patel SP, He K, Lynch RJ, Schaubel DE, Harbaugh C, Holcombe SA, Wang SC, Segev DL, Sonnenday CJ. Sarcopenia and mortality after liver transplantation. J Am Coll Surg. 2010;211(2):271–8. doi: 10.1016/j.jamcollsurg.2010.03.039.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Fukui H, Saito H, Ueno Y, Uto H, Obara K, Sakaida I, Shibuya A, Seike M, Nagoshi S, Segawa M, Tsubouchi H, Moriwaki H, Kato A, Hashimoto E, Michitaka K, Murawaki T, Sugano K, Watanabe M, Shimosegawa T. Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol. 2016;51(7):629–50.CrossRefPubMedGoogle Scholar
  14. 14.
    Gluud LL, Dam G, Les I, Córdoba J, Marchesini G, Borre M, Aagaard NK, Vilstrup H. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev. 2015;(2): CD001939. doi:  10.1002/14651858.CD001939.pub3.
  15. 15.
    Gottschall CB, Pereira TG, Rabito EI. Álvares-Da-Silva MR4. Nutritional status and dietary intake in non-cirrhotic adult chronic hepatitis C patients. Arq Gastroenterol. 2015;52(3):204–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Grancini V, Trombetta M, Lunati ME, Zimbalatti D, Boselli ML, Gatti S, Donato MF, Resi V, D’Ambrosio R, Aghemo A, Pugliese G, Bonadonna RC, Orsi E. Contribution of β-cell dysfunction and insulin resistance to cirrhosis-associated diabetes: role of severity of liver disease. J Hepatol. 2015;63(6):1484–90. doi: 10.1016/j.jhep.2015.08.011.CrossRefPubMedGoogle Scholar
  17. 17.
    Hasse J, Gautam M, Saracino G, Jennings L. Malnutrition reduces survival in patients awaiting liver transplantation. (Abstract) Presented at American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week. 2015. Accessed 19 Sep 2016.
  18. 18.
    Hasse J, Strong S, Gorman MA, Liepa G. Subjective global assessment: alternative nutrition-assessment technique for liver-transplant candidates. Nutrition. 1993;9(4):339–43.PubMedGoogle Scholar
  19. 19.
    Hasse JM, DiCecco SR. Enteral nutrition in chronic liver disease: translating evidence into practice. Nutr Clin Pract. 2015;30(4):474–87. doi: 10.1177/0884533615591058.CrossRefPubMedGoogle Scholar
  20. 20.
    Holecek M. Evidence of a vicious cycle in glutamine synthesis and breakdown in pathogenesis of hepatic encephalopathy-therapeutic perspectives. Metab Brain Dis. 2014;29(1):9–17. doi: 10.1007/s11011-013-9428-9.CrossRefPubMedGoogle Scholar
  21. 21.
    Kaido T, Ogawa K, Fujimoto Y, et al. Impact of sarcopenia on survival in patients undergoing living donor liver transplantation. Am J Transplant. 2013;13(6):1549–56.CrossRefPubMedGoogle Scholar
  22. 22.
    Krell RW, Kaul DR, Martin AR, Englesbe MJ, Sonnenday CJ, Cai S, Malani PN. Association between sarcopenia and the risk of serious infection among adults undergoing liver transplantation. Liver Transpl. 2013;19(12):1396–402. doi: 10.1002/lt.23752.CrossRefPubMedGoogle Scholar
  23. 23.
    Kynci JA, Chodash HB, Tsang T-K. PEG in a patient with ascites and varices. Gastrointest Endosc. 1995;42(1):100–1.CrossRefPubMedGoogle Scholar
  24. 24.
    Leise MD, Poterucha JJ, Kamath PS, Kim WR. Management of hepatic encephalopathy in the hospital. Mayo Clin Proc. 2014;89(2):241–53. doi: 10.1016/j.mayocp.2013.11.009.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Löser C, Aschl G, Hébuterne X, et al. ESPEN guidelines on artificial enteral nutrition-percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24:848–61.CrossRefPubMedGoogle Scholar
  26. 26.
    McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG clinical guideline: nutrition therapy in the adult hospitalized patient. Am J Gastroenterol. 2016;111(3):315–34. quiz 335 doi: 10.1038/ajg.2016.28.CrossRefPubMedGoogle Scholar
  27. 27.
    McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, Mc Carthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C, Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. doi: 10.1177/0148607115621863.CrossRefPubMedGoogle Scholar
  28. 28.
    Metcalfe EL, Avenell A, Fraser A. Branched-chain amino acid supplementation in adults with cirrhosis and porto-systemic encephalopathy: systematic review. Clin Nutr. 2014;33(6):958–65. doi: 10.1016/j.clnu.2014.02.011.CrossRefPubMedGoogle Scholar
  29. 29.
    Meza-Junco J, Montano-Loza AJ, Baracos VE, Prado CM, Bain VG, Beaumont C, Esfandiari N, Lieffers JR, Sawyer MB. Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma. J Clin Gastroenterol. 2013;47(10):861–70. doi: 10.1097/MCG.0b013e318293a825.CrossRefPubMedGoogle Scholar
  30. 30.
    Montano-Loza AJ. Clinical relevance of sarcopenia in patients with cirrhosis. World J Gastroenterol. 2014a;20(25):8061–71.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Montano-Loza AJ. Muscle wasting: a nutritional criterion to prioritize patients for liver transplantation. Curr Opin Clin Nutr Metab Care. 2014b;17(3):219–25. doi: 10.1097/MCO.0000000000000046.CrossRefPubMedGoogle Scholar
  32. 32.
    Montano-Loza AJ, Meza-Junco J, Prado CM, Lieffers JR, Baracos VE, Bain VG, Sawyer MB. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2012;10(2):166–73, 173.e1. doi: 10.1016/j.cgh.2011.08.028.CrossRefPubMedGoogle Scholar
  33. 33.
    O’Shea RS, Dasarathy S, McCullough AJ. Practice Guideline Committee of the American Association for the Study of Liver. Alcoholic liver disease. Hepatology. 2010;51(1):307–28.CrossRefPubMedGoogle Scholar
  34. 34.
    Parli SE, Ruf KM, Magnuson B. Pathophysiology, treatment, and prevention of fluid and electrolyte abnormalities during refeeding syndrome. J Infus Nurs. 2014;37(3):197–202. doi: 10.1097/NAN.0000000000000038.CrossRefPubMedGoogle Scholar
  35. 35.
    Phillips MS, Ponsky JL. Overview of enteral and parenteral feeding access techniques: principles and practice. Surg Clin North Am. 2011;91(4):897–911.CrossRefPubMedGoogle Scholar
  36. 36.
    Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr. 2006;25(2):285–94.CrossRefPubMedGoogle Scholar
  37. 37.
    Runyon BA. Practice guideline: management of adult patients with ascites due to cirrhosis. Update. 2012. AASLD website. Accessed 25 Sept 2016.
  38. 38.
    Sasidharan M, Nistala S, Narendhran RT, Murugesh M, Bhatia SJ, Rathi PM. Nutritional status and prognosis in cirrhotic patients. Trop Gastroenterol. 2012;33(4):257–64.CrossRefPubMedGoogle Scholar
  39. 39.
    Schlein K. Gastric versus small bowel feeding in critically ill adults. Nutr Clin Pract. 2016;31(4):514–22.CrossRefPubMedGoogle Scholar
  40. 40.
    Shangraw RE, Rabkin JM, Lopaschuk GD. Hepatic pyruvate dehydrogenase activity in humans: effect of cirrhosis, transplantation, and dichloroacetate. Am J Physiol. 1998;274(3 Pt 1):G569–77.PubMedGoogle Scholar
  41. 41.
    Skipper A. Refeeding syndrome or refeeding hypophosphatemia: a systematic review of cases. Nutr Clin Pract. 2012;27(1):34–40. doi: 10.1177/0884533611427916.CrossRefPubMedGoogle Scholar
  42. 42.
    Tandon P, Low G, Mourtzakis M, Zenith L, Myers RP, Abraldes JG, Shaheen AA, Qamar H, Mansoor N, Carbonneau M, Ismond K, Mann S, Alaboudy A, Ma M. A model to identify sarcopenia in patients with cirrhosis. Clin Gastroenterol Hepatol. 2016;14(10):1473–1480.e3. pii: S1542-3565(16)30198-7 doi: 10.1016/j.cgh.2016.04.040.CrossRefPubMedGoogle Scholar
  43. 43.
    Tandon P, Ney M, Irwin I, Ma MM, Gramlich L, Bain VG, Esfandiari N, Baracos V, Montano-Loza AJ, Myers RP. Severe muscle depletion in patients on the liver transplant wait list: its prevalence and independent prognostic value. Liver Transpl. 2012;18(10):1209–16. doi: 10.1002/lt.23495.CrossRefPubMedGoogle Scholar
  44. 44.
    Teiusanu A, Andrei M, Arbanas T, Nicolaie T, Diculescu M. Nutritional status in cirrhotic patients. Maedica (Buchar). 2012;7(4):284–9.Google Scholar
  45. 45.
    Tsien C, Davuluri G, Singh D, Allawy A, Ten Have GA, Thapaliya S, Schulze JM, Barnes D, McCullough AJ, Engelen MP, Deutz NE, Dasarathy S. Metabolic and molecular responses to leucine-enriched branched chain amino acid supplementation in the skeletal muscle of alcoholic cirrhosis. Hepatology. 2015;61(6):2018–29. doi: 10.1002/hep.27717.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Vieira PM, De-Souza DA, Oliveira LC. Nutritional assessment in hepatic cirrhosis; clinical, anthropometric, biochemical and hematological parameters. Nutr Hosp. 2013;28(5):1615–21. doi: 10.3305/nh.2013.28.5.6563.PubMedGoogle Scholar
  47. 47.
    Vilstrup H, Amodio P, Bajaj J, Cordoba J, Ferenci P, Mullen KD, Weissenborn K, Wong P. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology. 2014;60(2):715–35. doi: 10.1002/hep.27210.CrossRefPubMedGoogle Scholar
  48. 48.
    Yarze JC. Peritonitis after PEG placement in patients with cirrhotic ascites. Gastrointest Endosc. 2011;73(5):1071.CrossRefPubMedGoogle Scholar
  49. 49.
    Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73–84. doi: 10.1002/hep.28431.CrossRefPubMedGoogle Scholar
  50. 50.
    Zhu GQ, Shi KQ, Huang S, Wang LR, Lin YQ, Huang GQ, Chen YP, Braddock M, Zheng MH. Systematic review with network meta-analysis: the comparative effectiveness and safety of interventions in patients with overt hepatic encephalopathy. Aliment Pharmacol Ther. 2015;41(7):624–35. doi: 10.1111/apt.13122.CrossRefPubMedGoogle Scholar
  51. 51.
    Ukleja A, Freeman KL, Gilbert K, Kochevar M, Kraft MD, Russell MK, Shuster MH, Task force on standards for nutrition support: adult hospitalized patients, and the American Society for parenteral and enteral nutrition board of directors. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403–14. doi: 10.1177/0884533610374200.CrossRefPubMedGoogle Scholar
  52. 52.
    Hasse JM. Nutrition assessment and support of organ transplant recipients. JPEN J Parenter Enteral Nutr. 2001;25:120–31.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Annette C. and Harold C. Simmons Transplant InstituteBaylor University Medical CenterDallasUSA
  2. 2.Department of Internal MedicineTexas A&M College of MedicineBryanUSA
  3. 3.Simmons Transplant Institute, Baylor All Saints Medical CenterFort WorthUSA

Personalised recommendations