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Nutrition in Chronic Liver Disease: Clinical Practice Guidelines
Nutrition in Chronic Liver Disease: Clinical Practice Guidelines
Nutrition in chronic
liver disease
About these slides
• Please feel free to use, adapt, and share these slides for your own
personal use; however, please acknowledge EASL as the source
About these slides
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• Chair
– Manuela Merli
• Panel members
– Shira Zelber-Sagi, Srinivasan Dasarathy, Sara Montagnese,
Laurence Genton, Mathias Plauth, Albert Parés, Annalisa Berzigotti
(EASL Governing Board Representative)
Outline
• Questions to address were first established, taking into account relevance, urgency
and completeness of each
• Key questions addressed:
– How to recognize nutritional problems. In which conditions is nutritional
assessment recommended?
– What are the available methods of evaluation?
– What are the consequences of malnutrition and its correction in different
clinical scenarios
– Nutrition in chronic liver disease
– Nutrition in hepatic encephalopathy
– Nutrition before and after liver transplantation
– Bone metabolism in chronic liver disease
• A literature search was performed in different databases to identify references.
Pertinent key words were defined for each specific topic of the Guideline
• Reference selection was based on appropriateness of study design, number of
patients, and publication in peer-reviewed journals. Original data were prioritised
Background
The burden of malnutrition in liver cirrhosis
Malnutrition definition
Mechanisms and potential targets for sarcopenia
Prevalence and implications of malnutrition and
sarcopenia in cirrhosis
• Malnutrition and muscle mass loss (sarcopenia), which has been often
used as an equivalent of severe malnutrition, are associated with a
higher rate of complications
– Susceptibility to infections
– Hepatic encephalopathy
– Ascites
– Independent predictors of lower survival in cirrhosis and in patients
undergoing liver transplantation
• Muscle mass depletion may also occur in these patients, but due to
the coexistence of obesity, sarcopenia might be overlooked
†
In a 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
Nutritional management principles in patients with
liver cirrhosis
Dear patient,
• Most of what you have heard/read on the relationship between food and the
liver has limited scientific evidence to support it. Generally, healthy eating of a
variety of foods is advisable to all patients
• Virtually no food other than alcohol actually damages the liver and/or is
genuinely contraindicated in patients with chronic liver disease
• 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 fruit 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
Short, practical dietary advice for bedside or
outpatient clinic use
• Patients with liver disease may have hepatic encephalopathy, which may make
them tolerate animal proteins (meat) less well than vegetable proteins (beans,
peas etc) and dairy proteins. Before you make any changes to your protein
intake, you should always ask your doctor or dietician. Please do not reduce
your total protein intake as it is not advisable in cirrhosis
• Some patients with liver disease have other diseases, for example diabetes or
are overweight/obese, which require dietary adjustments. Please remember to
tell your doctor about all your illnesses and about any dietary advice you have
already received from other doctors, nurses or dieticians
Diagnosis and management of bone disease in
patients with chronic liver disease
*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
Risk factors for the development of osteoporosis in
chronic liver disease
• Alcohol abuse
• Smoking
• Body mass index <19 kg/m2
• Male hypogonadism
• Early menopause
• Secondary amenorrhea of more than 6 months
• Family history of osteoporotic fracture
• Treatment with corticosteroids (≥5 mg/d prednisone for ≥3 months)
• Advanced age
Nutritional treatment options for patients with bone
diseases