Outline review of nutritional assessment, and management in cirrhosis patients

A comprehensive review evaluated the ways in which proper nutrition can help reduce the adverse effects of hepatic encephalopathy in patients with hepatic encephalopathy.

A recent review was published in Journal of Clinical Medicine Discover proper nutrition for patients with hepatic encephalopathy, a complication liver cirrhosis. The review identified ways in which proper nutrition, or lack thereof, can be correctly identified in patients and how eating certain healthy foods can help counter the threats of malnutrition and obesity.

Hepatic hepatic impairment is the most common complication of cirrhosis, affecting between 35% and 40% of all patients with cirrhosis. Hepatic encephalopathy is defined as a patient with altered cognitive status and neuromuscular function, which makes proper nutrition to maintain muscle mass important for these patients.

Decreased carbohydrate metabolism and improved protein metabolism lead to abnormal energy production in patients with cirrhosis and faster burning of proteins due to the increased need of the body. This often results in altered nutritional status in patients with cirrhosis, including malnutrition, which some studies have postulated to be the most common complication of cirrhosis. Malnutrition can adversely affect the patient’s prognosis and exacerbate anorexia – wasting, a cycle of lack of appetite and loss of weight and muscle.

Protein and calorie malnutrition is associated with more complications of cirrhosis, including hepatopathy, impaired liver function, and mortality. The patients with the worst prognosis for cirrhosis are those with sarcopenia and myoclonus, both of which affect muscle mass.

Therefore, nutrition assessment and management is vital, according to the review authors. However, they noted that it is difficult to obtain a diagnosis of malnutrition in the early stages of cirrhosis, and there is no consensus on the best way to diagnose and classify it. The initial step in evaluating patients with cirrhosis is to determine their nutritional status.

However, there are limitations to determining nutritional status, including:

  • Differences in body composition between the sexes and tissue loss limiting tools for measuring muscle mass in women
  • There is no standardized approach to diagnosing malnutrition
  • Fluid retention makes body weight and mass unreliable
  • Biochemical markers are affected by plasma dilution and altered hepatic synthesis
  • More accurate measurements have high costs and are not always available

Nutritional status is currently being assessed without instruments using food diaries, objective examinations, biochemical parameters, and micronutrient dosage. Tools that have been used to assess nutritional status include bioimpedance testing, hand grip strength tests, DEXA scan, indirect measurement, computed tomography, and global physical performance assessment. However, most of these tools have negative aspects, including limited applicability to women, limitations in patients with electrolyte disturbances, and water imbalance.

The European Society for Enteral and Parenteral Nutrition guidelines suggest a multiparameter method for nutritional assessment, using indirect measures such as the Personal Global Assessment Questionnaire and anthropometric assessment. These assessments are sensitive and can identify patients most at risk of malnutrition.

The review continues to suggest that patients with cirrhosis require proper nutrition to avoid muscle loss and to achieve a positive nitrogen balance. Patients should have a daily caloric intake of 30 kcal/kg per day. The energy intake of obese patients should be reduced to 20 to 25 kcal/kg per day and they should eat 4 to 6 meals per day to prevent gluconeogenesis.

Protein intake should be around 1 to 1.5 g/kg per day to prevent sarcopenia and improve nitrogen balance, and protein should be consumed primarily at night to encourage further gains in muscle mass. Consuming protein-rich vegetables has been found to improve HE. Patients with cirrhosis and HE should consume 25 to 45 grams per day of fruits and vegetables with fiber. There are currently no recommendations for carbohydrate, fat, or protein supplementation.

The authors conclude that nutritional assessment and management of patients with cirrhosis and HE can help address the negative effects of both and can improve prognosis. Evaluation of nutritional status should be the first step in establishing nutritional control for these patients.

“It will be necessary to manage patients in a multidisciplinary team that includes a specialized dietitian and treat this aspect even in the early stages of the disease, in order to prevent the onset of sarcopenia and other potential complications of cirrhosis such as hepatic encephalopathy,” the authors wrote.


Faccioli J, Nardelli S, Gioia S, Riggio O, Ridola L. Nutrition assessment and management in patients with cirrhosis and cognitive impairment: a comprehensive review of the literature. J Clean Med. 2022; 11:2842. doi: 10.3390/jcm11102842