Definition

Cirrhosis represents the end stage of liver scarring (fibrosis), where liver cells are entirely surrounded by scar tissue. The Child-Pugh classification ¹ is the most commonly used system for staging cirrhosis. It categorizes liver function into three stages: In stage A, liver function is usually largely preserved, while in stage C, significant hepatic insufficiency must be assumed. The MELD score is another tool used to assess the severity of cirrhosis ². Both the Child-Pugh ¹ and MELD scores ² help evaluate prognosis. As metabolic cirrhosis increases, so does the number of obese patients with cirrhosis. In this group, sarcopenia must be actively screened for, as it is often not recognizable as a visual diagnosis.

Advanced liver cirrhosis is characterized by a disruption of carbohydrate, protein, and lipid metabolism and a reduction in hepatic glycogen stores, requiring greater reliance on gluconeogenesis to produce energy ^{3, 4}. Thus, the nightly fasting phases resemble a longer period of hunger in healthy individuals. Insulin resistance often occurs, with 15-38% of patients progressing to diabetes mellitus ⁵.

Impact on Nutritional Status

Protein-energy malnutrition and mineral deficiencies occur in about 20-50% of patients and are associated with increased mortality and risk of complications ⁶. Pronounced protein deficiency in liver cirrhosis patients can lead to sarcopenia, resulting in a significant loss of muscle function. Malnutrition in these patients is often associated with complications such as ascites and hepatorenal syndrome ⁴. To quickly identify the risk of malnutrition or existing malnutrition, standardized screening using Nutritional Risk Screening 2002 (NRS 2002) or Subjective Global Assessment (SGA) should be performed, followed by anthropometric assessment. If the screening is positive (i.e., sarcopenia is present), nutritional therapy should be initiated. To ensure adequate nutrition, food restrictions should be avoided as much as possible ⁷.

Nutrient requirements of patients with liver cirrhosis. Adjustments are necessary for malnourished patients, physical activity and age of the patient. The weight used is the adjusted body weight (ADJ) from BMI 28, otherwise the body weight before hospital admission. BW = body weight; d = day; NE = not malnourished; SA = sarcopenic obese; ME = malnourished or sarcopenic patients with liver cirrhosis.

Aims of Nutritional Therapy

• Maintenance or improvement of nutritional status
• Prevention of malnutrition or nutrient deficiencies
• Reduction of fasting phases
• Complete abstinence from alcohol
• Limitation of fluid and, if necessary, sodium intake in patients with ascites (in consultation with the treating physician)

Energy and protein requirements should be covered by oral nutrition whenever possible. If less than 75% of the requirement is met through dietary enrichment, snacks, or sip feeds, enteral nutrition should be introduced as a supplement no later than five days. Complementary parenteral nutrition should be initiated if less than 75% of the requirement is covered by enteral and/or oral nutrition. For detailed guidance, refer to the chapter on enteral and parenteral nutrition.

General Nutritional Recommendations

Due to the significant variation in requirements over the course of the disease, the energy requirement should be determined by indirect calorimetry if possible. An increased protein intake is often indicated to maintain fat-free body mass.

Oral Nutrition

Regular main and intermediate meals, as well as a late meal before bed, can optimize energy and protein intake and shorten the fasting period at night ⁷. For malnourished cirrhosis patients who cannot meet their nutritional needs orally, supplemental sip feeds are recommended. These should be high in energy and protein and should be administered in the evening (e.g., two 200 mL standard formula drinks with 300 kcal and 19 g protein in the evening after 8:00 PM) ^{9, 10}. Total protein intake should not be reduced if possible, including for patients with encephalopathy ^{11, 12}.

The prevalence of obese liver cirrhosis patients has increased in recent years. In this group, a hypocaloric diet should be administered, and physical activity increased ¹².

Practical Tips (if indicated)

• Recommended meal composition to meet increased energy and protein needs:
  • Avoid unnecessary restrictions; increase well-tolerated foods if indicated.
  • Include a starchy side dish with each main meal; starchy foods should constitute the largest portion of the meal by quantity.
  • Include a protein side dish with each main meal; incorporate both animal and plant-based protein sources; adjust protein intake to meet requirements.
  • Use fats and oils for preparation and to enrich menu components.
  • Incorporate vegetables and salads, but reduce their quantity (caution: high volume, low energy and protein content); omit if they cause a feeling of fullness.
  • Regularly include energy-dense foods such as sweetened beverages, fruit juices, sweets, desserts, nuts, and sweeteners (e.g., sugar or honey) (caution: diabetes).
• Avoid long fasting periods: take sip feeds, carbohydrate- and protein-rich snacks, and a late meal, as well as an early meal in the morning ¹².
• If ascites and/or edema are present, reduce salt intake (in preparation and salty foods).
• Include three to five servings of dietary fiber per day to regulate the microbiome and reduce toxin production, such as ammonia. High-fiber foods include whole grains, oat bran, and vegetables ¹².
• Lactulose to improve intestinal transit and for prophylaxis or treatment of hepatic encephalopathy; converted by intestinal microbiota into acetates and lactate, it acidifies intestinal contents, indirectly reducing bacterial protein fermentation and improving hepatic encephalopathy by lowering ammonia production ¹².
• For esophageal varices at high risk for or with recent bleeding: soft foods, chew food well, or puree to reduce injury and pain ¹².

Enteral Nutrition

Patients unable to meet their energy and protein requirements orally should receive a fully balanced, high-molecular-weight standard diet or hypercaloric enteral nutrition (1.5 kcal/mL) with low sodium content (40 mmol/d) administered enterally ^{4, 10}. Enteral nutrition is primarily provided via a nasojejunal tube; nasogastric tubes are used only in exceptional cases. Nighttime administration is preferred. Esophageal varices are not considered a contraindication for enteral tube feeding. However, percutaneous endoscopic gastrostomy (PEG) should be avoided in these patients due to the increased risk of complications, particularly in the presence of ascites or coagulation disorders ¹³.

Parenteral Nutrition

In patients at high risk of encephalopathy, parenteral nutrition solutions enriched with branched-chain amino acids (BCAAs) can improve mental status, though survival outcomes are not affected. For other liver cirrhosis patients, standard parenteral nutrition solutions are sufficient ⁷.

Monitoring

• Monitor potassium, magnesium, and phosphate levels, as malnourished liver cirrhosis patients are often at risk of refeeding syndrome ⁷.
• Monitor and, if needed, substitute zinc and selenium due to the high prevalence of deficiencies ⁷.
• Supplement water-soluble vitamins, especially B vitamins, as deficiencies are common in patients with alcohol-induced liver cirrhosis ⁷.
• Fat-soluble vitamin deficiencies frequently occur in cholestasis-related steatorrhea, bile salt deficiency, and active alcohol consumption ⁷.

Special Considerations

• Restrict sodium intake only if adequate food intake can still be guaranteed ⁷.
• Plasma concentrations of essential and polyunsaturated fatty acids are often reduced, correlating with nutritional status and the severity of liver disease ⁷.
• Albumin synthesis correlates with quantitative liver function tests and the clinical stage of liver cirrhosis, whereas fibrinogen synthesis does not ⁷.
• In rare cases where protein intake of more than 1 g/kg body weight per day is not tolerated, limiting protein to 0.5 g/kg body weight per day may be necessary. In such cases, supplementation with 0.25 g/kg body weight per day of branched-chain amino acids (BCAAs) can help improve nitrogen balance without increasing the risk of encephalopathy ^{9, 13, 14}.

Medications/Supplements

• Branched-chain amino acids (BCAAs): valine, leucine, isoleucine
• Duphalac (lactulose)