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Viral Hepatitis and Liver Disease

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Nutrition and Cirrhosis

for Health Care Providers

Nutrition and Cirrhosis - Cirrhosis

Malnutrition is a consequence of advanced liver disease (ALD) for 20-60% of patients with cirrhosis. It is associated with increased risk of mortality, higher prevalence of portal hypertension-related complications, infections and longer stays in the hospital.

Major reasons for malnutrition in cirrhosis

  • Decreased oral intake caused by poor appetite, nausea, ascites, taste alterations, bland tasting diets, medications and ongoing alcohol use.
  • Decreased utilization of nutrients caused by fat malabsorption, bile acid deficiency, effects of portal hypertension including gastropathy and enteropathy, presence of bacterial overgrowth and chronic use of lactulose can be complications of cirrhosis.
  • Altered metabolism of carbohydrates and proteins can result from insulin resistance, promotion of gluconeogenesis, abnormal amino acid metabolism and increase in protein catabolism.
  • A starvation state can result from the reductions in glucose, protein and lipids.

Understanding nutritional issues for patients with cirrhosis

There is no universal tool to evaluate nutritional status in ALD. The assessment should be continuous during the care of the patient. Ideally, patients should also be seen by a registered dietitian. Weight changes, diet history, GI symptoms, severity of liver disease and evaluation of micronutrient deficiencies are important parameters.

Weight and body composition changes: When assessing women, it is important to recognize that they have lower muscularity and more fat stores compared to men at baseline. Muscle loss is more evident in men over time. Weight losses and gains should be evaluated. Dry weight should be used to estimate the weight changes, however, salt and water retention, diuretic therapy and paracentesis make evaluation of true weight difficult. Dry weight loss >10% in 6 months or less is considered severe.

Dietary intake: Diet history including portion sizes, nutrient content and fluid intake should be assessed. Barriers to intake include altered taste, unpalatable taste of low-sodium diet, early satiety especially with ascites, and lack of funds for purchasing healthier food choices.

GI symptoms: Gastrointestinal symptoms such as nausea, vomiting, and diarrhea should be assessed. Losses affect both nutritional and fluid status. Sedating anti-nausea drugs should be avoided. Medications such as ondansetron may be better tolerated. Rifaximin for hepatic encephalopathy may decrease induced diarrhea caused by lactulose.

Excretion: Inability of the kidneys to handle water causes hyponatremia and activation of the anti-diuretic hormone (ADH) resulting in water retention.

Cirrhosis assessment: Severity of liver disease should be determined using either the Model for End-Stage Liver Disease (MELD) or the Child-Turcotte-Pugh (CTP) score. Individuals in CTP- C class are almost always malnourished. However, malnutrition begins in early liver disease.

Physical examination

Feet, ankles, and the sacral area should be assessed for edema. Ascites >500 ml can be detected by bulging flanks, shifting dullness and fluid waves. Lesser amounts of fluid can be detected by ultrasound.

Fat loss is assessed around the eyes, triceps, and ribs. Muscle status assessment should be assessed for both loss of bulk and tone. Areas evaluated include the temporalis pectoralis, clavicles, shoulders (deltoid), interosseous muscle, scapula, thigh (quadriceps) and calf. Mid-arm muscle circumference (MAMC) and triceps skin fold thickness (TST) are predictors of loss of lean body tissue in liver disease. Individuals with nonalcoholic fatty liver disease (NAFLD) may have atrophied skeletal muscle masked by adipose tissue. Nutritional status measuring fat loss and muscle wasting are gauged as nourished, mild/moderate or severe. Handgrip strength assessed by dynamometry has high diagnostic accuracy in determining nutritional status.

Laboratory evaluation

Serum albumin and pre-albumin are not reliable in assessing for malnutrition when liver disease is present. If an accurate collection can be arranged, a 24-hour urine creatinine >18 mg/kg ideal body weight (IBW) in women and >23 mg/kg IBW in men suggests normal muscle mass in those with normal renal function.

Laboratory measurement of micronutrients may be performed if etiology of sign or symptom is unclear or if there is concern for possible toxicity (see below). Specific considerations can include low fat-soluble vitamin levels in cholestatic liver disease such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC).

Micronutrient deficiencies in liver disease

MicronutrientSigns and Symptoms of Deficiency
Vitamin ADermatitis, night blindness, photophobia
Thiamine (Vitamin B1)Loss of appetite, fatigue, irritability, paresthesia, weakness, nausea/vomiting, decreased LE reflexes
Niacin (Vitamin B3)Dermatitis, glossitis
Pyridoxine (Vitamin B6)Paresthesia, confusion
Cyanocobalamin (Vitamin B12)Glossitis, angular stomatitis, decreased LE reflexes
ZincWeight loss, poor wound healing, decreased alertness, diarrhea, decreased appetite, dermatitis, muscle cramps
MagnesiumMuscle cramps, fatigue, irregular heart rate
FolateGlossitis, fatigue, headaches, weight loss, decreased hunger, diarrhea, paresthesia
Ascorbic acid (Vitamin C)Bruising, bleeding, fatigue, joint pain, rough skin
Vitamin KBruising, excessive bleeding

Feeding routes

It is desirable for individuals to meet their calorie and protein needs with normal food whenever safe and possible. If necessary, tube feedings are given per nasoenteral tubes rather than percutaneous tubes which are considered unsafe in the presence of gastric varices or ascites.


Energy recommendations:

  • Indirect Calorimeter measurements for caloric needs is the gold standard
  • 25-30 kcal/kg per day based on dry weight
  • 1.2-1.4 kcal/kg x REE is recommended for total energy intake

Protein recommendations:

  • Guidelines recommend a daily protein intake of 1.0-1.5 g/kg of dry body weight.
  • Protein restriction is not recommended and does not have benefits for hepatic encephalopathy.
  • Overnight fasting is discouraged due to worsening of muscle depletion. Late evening meals are recommended as this improves nitrogen balance, particularly high-protein late evening meals.

Sodium recommendations:

  • 2000 mg limit in sodium per day is mandatory for patients with ascites.

Fluid recommendations:

  • For patients with hyponatremia with sodium of <120-125 mmol/L, fluid restriction is recommended at 1 to 1.5 L/day.

Alcohol recommendations:

  • Patients should be counseled that no amount of alcohol is considered safe in cirrhosis.
  • Individuals should be questioned about specific amounts of all types of alcohol consumed including beer, wine, coolers, whiskey, gin, rum, brandy and liquors.
  • Individuals should be reminded that non-alcoholic beer and kombucha contains a small amount of alcohol.

Vitamin recommendations:

  • Deficiencies of zinc, thiamine, niacin, pyridoxine, folate and magnesium may be present, and symptoms improved by supplementation. Zinc supplementation of 50 mg oral elemental zinc is typically tolerated in liver disease. Monitor copper levels to prevent copper deficiency.
  • Excessive amounts of Vitamin A and D may be harmful.
  • Vitamin C should not be given to individuals with hemochromatosis because of the danger of iron overload due to enhanced iron absorption.