Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach

Abstract

Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.

Keywords: Cirrhosis; Diet; Guidelines; Nutritional diagnosis; Treatment.

Figure 1

Impact of sarcopenia in cirrhosis. The presence of sarcopenia has been shown to be associated with reduced quality of life and survival. It is a predictor of pre and posttransplant complications, including higher risk of infections, ascites, hepatic encephalopathy, and longer hospital stay. HE: Hepatic encephalopathy. Citation: The authors have obtained the permission for figure using from the BioRender.com (Supplementary material)[112].

Figure 2

Assessment in patients with cirrhosis. Implementing the nutritional control protocol outlined by Clinical Practice Guidelines is strongly advised as a fundamental aspect of standard cirrhosis patient management. HE: Hepatic encephalopathy; INR: International normalized ratio; CBC: Complete blood count; CT: Computed tomography; DEXA: Dual energy X-ray absorptiometry; BIA: Bioelectrical impedance analysis; BMI: Body mass index; RFH-NPT: Royal Free Hospital Nutritional Prioritizing Tool. The consent was adapted by Clinical Practice Guidelines[41]. Citation: The authors have obtained the permission for figure using from the BioRender.com (Supplementary material)[112].

Figure 3

The nutritional care process includes the following steps. (1) Nutritional assessment; (2) nutritional diagnosis; (3) nutritional intervention; and (4) monitoring. LFI: Liver frailty index; RFH-NPT: Royal Free Hospital Nutritional Prioritizing Tool; CT: Computed tomography; DEXA: Dual energy X-ray absorptiometry; BIA: Bioelectrical impedance analysis; BMI: Body mass index. Citation: The authors have obtained the permission for figure using from the BioRender.com (Supplementary material)[112].

Figure 4

General recommendations for nutritional intervention in patients with cirrhosis. BCAAs: Branched-chain amino acids. Citation: The authors have obtained the permission for figure using from the BioRender.com (Supplementary material)[112].