UPDATED CPG:

NUTRITION SUPPORT IN
LIVER DISEASE
Narisorn Lakananurak MD. MSc.
Physician Nutrition Specialist
November 24, 2021
2018 2019 2021
 Diagnosis
Severity
Causes

Nutrition Nutrition Nutrition

Monitoring
Screening Assessment Management

J Parenter Enteral Nutr 2011;35: 16

 COMMON
100

80

60 Mild PEM
Moderate PEM
40 Severe PEM

20

0
Child A Child B Child C
46.2% 84.1% 94.6%
Arq Gastroenterol 2006; 43(4): 269–74
 POOR OUTCOMES
100 100
90
80 80 64.6
65
70
60 60 47.8
50
40 40
20 30
11 14.1
20 20 7.5 5.12.8
0 10
0 0
1 yr Mortality Complications Mortality Ascites HRS
Malnourished Malnourished
Wellnourished Wellnourished Nutrition 2005; 21: 113–7
Liver Int. 2009; 29(9): 1396-402
 Sarcopenia

2X

2.5X
decompensation

1.6X

4.6X
Clin Gastroenterol Hepatol. 2012 Feb;10(2):166-73
JHEP Rep. 2019 Dec 5;2(1):100061.

Liver Transpl 2014;20(6):640-648.

Eur J Gastroenterol Hepatol 2019;31(12):1550-1556.

myo steatosis woodrat urinal
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:166–173
J Cachexia Sarcopenia Muscle 2015;7(2):126-135.
Topics EASL 2018 ESPEN 2019 AASLD 2021

- Perform a rapid nutrition screen in - Liver disease patients should be All patients with cirrhosis
Who All patients with cirrhosis screened for malnutrition using a
validated tool.

- High risk: BMI <18.5 kg/m2, Child- - The Best Option: RFH-NPT - Most consistent tool: RFH-NPT
How Pugh C, Use nutritional screening - Others: NRS 2002
tools in all other instances.
- Liver disease specific tools: RFH-
NPT, The liver disease
undernutrition screening tool
(subjective, low NPV)
- Others: not validated, bias from
fluid retention
 Topics EASL 2018 ESPEN 2019 AASLD 2021

- The components of a detailed nutritional - Nutrition status can be assessed using -

How assessment: global assessment tools (SGA,
RFH-GA), detailed dietary intake, and muscle
bedside methods: SGA, modified RFH-GA,
Handgrip strength, BIA (phase angle)
mass.
- Assess dietary intake by trained personnel
(ideally a dietician).
Assessment should include: quality and
quantity of food and supplements, fluids,
sodium, number and timing of meals barriers
to eating.
- Include an assessment of sarcopenia within - Sarcopenia should be assessed (strong - All patients with cirrhosis should be
Sarcopenia the nutritional assessment.
- Assess sarcopenia in obese patients with
predictor of morality and morbidity).
- CT/MRI when available or DEXA
assessed for frailty.
- Insufficient data to recommend the use of

and Frailty cirrhosis

- Sarcopenia: CT at L3 when available, ใ ด sarcopenia
standard
one frailty tool (e.g. Fried frailty, handgrip
strength, SPPB)
alternatives = Anthropometry, DEXA, BIA + CT -
L3 →
goal - Objective measure of muscle loss should be
muscle function (handgrip strength, SPPB) considered to assess risk for poor outcomes in
MRI
hand patients with cirrhosis.
ห อ BIA ,
-

grip
- CT/MRI when available, insufficient data for a
bedside tool
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 Nutrition
Screening: Nutrition
- BMI <18.5kg/m2
All - Child C Assessment
- Positive nutrition - Tools: SGA, RFH-GA,
Cirrhosis screening tools (RFH- others
Patients NPT, others: beware - Dietary assessment
fluid overload) (+time and meal
number)
& Obesity
evaluation
Sarcopenia
evaluation
- CT/MRI at L3 if
available
- DEXA, BIA, MAMC,
MAMA
- Handgrip, SPPB
 Sarcopenia Criteria
Variables Measurements Gender AWGS JSH AWGS
2014 2015 2019
CT/MRI Male ≤42 cm2/m2
(L3 level)
Female ≤38 cm2/m2

DEXA Male <7.0 <7.0

kg/m2 kg/m2

Muscle mass Female <5.4 <5.4

kg/m2 kg/m2
BIA Male <7.0 <7.0 kg/m2 <7.0
kg/m2 kg/m2
Female <5.7 <5.7 kg/m2 <5.7
kg/m2 kg/m2
Phase angle in cirrhosis: Male ≤5.6°, Female ≤5.4°

Muscle strength Handgrip strength Male <26 kg <26 kg <28 kg

Female <18 kg <18 kg <18 kg
Gait speed by 6-meter walk <0.8 m/s <0.8 m/s <1 m/s

Physical Short Physical Performance ≤9

performance Battery
5-time chair stand test ≥12 s
 Topics EASL 2018 ESPEN 2019 AASLD 2021

- IC when possible - IC when possible - IC when possible

Non-Obese - ≥35 kcal/kg/day - 1.3 x REE (~32 kcal/kg/day, sedentary - ≥35 kcal/kg/day
- BW = Actual BW," corrected for ascites = lifestyle) - BW = Ideal BW
อย
า บวม อาจใ
""
ห ง ก ลบ แ ว หา "° "" "
subtract 5%, 10%, and 15% for mild, - 30-35 kcal/kg/day Ideci BW
มา า เ น obesity moderate, and severe ascites + subtract - BW = Actual BW for no ascites, Ideal
5% for bilateral leg edema e ขา บวม BW for ascites
ไ ห อไ * * ใ ลด ก
Actual BW 5%

- A tailored, moderately hypocaloric (- - Lifestyle intervention for weight - BMI 30-40 kg/m2: 25-35 kcal/kg/day
Obese 500-800 kcal/day) diet to achieve weight reduction (reduced portal - BMI >40 kg/m2: 20-25 kcal/kg/day
loss. hypertension) ใ idea BW (non-hospitalized, clinically stable)
- 25 kcal/kgIBW/day - Weight loss under supervision (caution
บ แ ง ระยะ น อง ลด BW in decompensated cirrhosis)

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 Topics EASL 2018 ESPEN 2019 AASLD 2021

- 1.2-1.5 g/kgABW/day - No malnutrition, compensated: 1.2 - 1.2-1.5 g/kgIBW/day

Non-Obese g/kg/day - Critical illness: 1.2-2 g/kgIBW/day
- Malnutrition/Sarcopenia: 1.5 - A diverse of protein sources, including
g/kg/day vegetable and dairy products

- >1.5 g/kgIBW/day - 2-2.5 g/kgIBW/day -

Obese
 EASL 2018 ESPEN 2019 AASLD 2021

- Administer micronutrients and vitamins - Micronutrients should be administered to treat - Micronutrient deficiencies should be assessed at
to treat confirmed or clinically suspected deficiency. confirmed or clinically suspected deficiency least annually, repleted if deficient, and
- Assess vitamin D levels in cirrhotic patients, as - Reported deficiency reassessed after repletion.
deficiency is highly prevalent and may adversely Vitamin: D, B1, Fat soluble (cholestasis) - Pragmatic approach: empiric course of
จะ เส ม เ อ
affect clinical outcomes. diniccil Trace elements: Zn, Se multivitamin supplementation in malnutrition,
frailty, or sarcopenia.
- Reported deficiency ขาด เ า น - Pragmatic approach: liberal supplementation in
- In patients who cannot meet nutrition target from
Vitamin: A, K (cholestasis), B1 the first 2 weeks of nutritional support
sodium-restricted diet, liberalization of sodium
Trace element: Zn, Se, Fe - Ascites: Moderate sodium diet (usually 60
restriction should be considered.
Toxicity: Mn (avoid supplement with Mn) mmol/day = 1,400 mg/day) but should balance
- Pragmatic approach: course of multivitamin against lower food consumption.
supplementation in decompensated patients.
- Ascites: Sodium restriction 2,000 mg/day – should
not below 1,400 mg/day, take care about diet
palatability.
- Evaluate BMD in cirrhosis, cholestasis, long-term
steroid, before LT (Lumbar and femoral DEXA)
- Osteoporosis/penia: Calcium 1,000-1,500 mg/day
and Vitamin D 400-800 IU/day + Bisphosphonate
(Osteoporosis)
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 Topics EASL 2018 ESPEN 2019 AASLD 2021

Oral → ONS → EN → PN Oral → ONS → EN → PN Oral → ONS → EN → PN

Recommendation

- Healthy eating with variety of foods
Oral - Avoid food restriction, except alcohol
- Minimize fasting time: frequent meals
(e.g. 3 main meals + 3 snacks) with late
evening snack and breakfast
- - NG can be placed even with
EN
- Minimize fasting time, with maximum - Minimize fasting time: 3-5 meals + late
interval of 3-4 hours between intake evening snack
during awake + early breakfast and late
evening snack
- NG can be placed even with
esophageal varices (beware after esophageal varices.
recent banding) - PEG is associated with complications
- PEG should not be placed in patients (due to ascites and varices), it can be
with ascites used in exceptional cases (mild ascites)
 EASL 2018
- Decompensated cirrhotic patients when adequate
nitrogen intake is not achieved by oral diet.
- Hepatic encephalopathy to improve symptom and
reach nitrogen intake.
- Critically ill cirrhosis with HE to facilitate resolution
ESPEN 2019 AASLD 2021
- Advanced cirrhosis to improve event-free - Not recommend beyond diverse protein source
survival or quality of life
- In patients with protein intolerant to facilitate
protein intake
- Hepatic encephalopathy in need of EN
 EASL 2018 ESPEN 2019 AASLD 2021

- Avoid protein restriction ไ ควร restrict
- Encourage vegetables and dairy protein
- Severe HE (grade III-IV): EN (protected
airway) or PN
- Protein should not be restricted - Protein should not be restricted
- Protein can be deferred for 24-48 hours - Do not recommend limiting meat-based
until hyper-ammonemia is controlled in protein, encourage to consume diverse
severe hyper-acute HE and highly elevated protein sources, including vegetable and
ammonia (risk of cerebral edema) dairy when possible
- Vegetable protein should be used in นใ พอ อน อย แนะ ใ น Plant protein
ห อ dairy product
patients with protein intolerant

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 EASL 2018 ESPEN 2019 AASLD 2021

Preoperative Preoperative -

- Goal 30 kcal/kg/day and Protein 1.2
g/kg/day (maintain nutrition), 35 kcal/kg/day
and Protein 1.5 g/kg/day (improve nutrition),
25 kcal/kg/day and Protein 2 g/kg/day
(obese)
- No role BCAA-enriched and immune-
enhancing in adults
Postoperative
- Early oral/EN within 12-24 hours
- Can use ERAS protocol
- After acute phase: goal 35 kcal/kg/day and
Protein 1.5 g/kg/day
- Goal 30-35 kcal/kg/day and Protein 1.2-
1.5 g/kg/day (non-obese), 25
kcal/kgIBW/day and Protein 2-2.5
g/kgIBW/day (obese)
- No role BCAA-enriched and immune-
enhancing in adults
Postoperative
- Early oral/EN within 12-24 hours
- EN with selected probiotics (Lactobacillus
sp.) can be used to reduce infection
- After acute phase: same goal as
preoperative
 Nutrition
Screening: Nutrition Nutrition
- BMI <18.5kg/m2
All - Child C Assessment Management
- Positive nutrition - Tools: SGA, RFH-GA, - Energy,
Cirrhosis screening tools (RFH- others Macronutrients,
Patients NPT, others: beware - Dietary assessment Micronutrients
fluid overload) (+time and meal - Route
number) - Others
& Obesity
evaluation
Sarcopenia
evaluation
- CT/MRI at L3 if
available
- DEXA, BIA, MAMC,
MAMA
- Handgrip, SPPB
 BW Energy Oral & ONS
- No ascites: Actual BW - IC when possible - Limited fasting time: Frequent
- Ascites: estimated dry - 30-35 kcal/kg/day meal (4-6 meals) + Late evening
weight or IBW snack and Early breakfast
Protein
- 1.2-1.5 g/kg/day
- No restriction even in HE (except short
EN
Nutrition period in severe, acute HE) - NG: EV is not contraindication.
- PEG: Beware in
Management - Diverse protein types, may prefer
vegetable/dairy in HE ascites/varices

Micronutrients
- Vitamin D level
PN
- Consider a course of MTV (e.g. 2 wks) in
Obesity
malnutrition, inadequate intake
- Consider weight reduction
5-10% esp. in compensated
- Low Na in ascites, consider food BCAAs
palatability - Decompensated cirrhosis with
cirrhosis
- BMD with Ca (1-1.5 g/d) and Vitamin D inadequate protein intake
- Hypocaloric, High protein
in osteoporosis/penia
(25 kcal/kgIBW/d + 1.5-2.5 - Protein intolrance
- Consider: AEK (esp. cholestasis), B1,
g/kgIBW/d)
Zn, and Avoid Mn supplementation
- May HE
 source เ น
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