Nutrition in Cirrhosis- a case-based review to chew on

Nutrition is important in the management of liver disease. I’m sure for anyone working with cirrhotic patients this is not news, and even for those without extensive nutrition training the fact that the skeletal, sarcopenic patients do very badly is a clear reality we experience regularly on the clinical coal face.

However, the challenge we often face on the medical side is understanding how this should be properly assessed beyond the ‘end-of-the-bed-o-gram,’ and faced by somewhat baffling guidelines about target numbers of kCal and grams of protein per day we often take a step back and leave it entirely to the dieticians. This is all well and good- the dieticians are the experts in nutritional calculations- but as clinicians with overarching responsibility for our patients, being equipped with the basic tools is helpful in several aspects of our care planning, including risk prognostication, timing of requesting dietician support (often needed sooner than we think), and optimisation of patients we want to send for transplant referral. Moreover, especially in the outpatient setting, a dietician may not be at hand to give the input that is required.

With that in mind, we have recently published an excellent article on the management of nutrition in cirrhosis which can be freely downloaded here and I highly recommend you take time to read it. Building on our tradition at Frontline to provide clinically focussed resources for clinicians, the article is built around a case with NASH cirrhosis in 3 key stages of their disease: compensated disease in the clinic, acute decompensation as an inpatient, and finally outpatient decompensated disease at which point transplant assessment is being considered. The choice of NASH as the underlying aetiology was a wise one, not only as this is rapidly becoming one of the most common cause of advanced liver disease in this country, but also the identification of ‘sarcopenic obesity’ can be challenging.

The article includes some information on the pathophysiology of sarcopenia in these patients, simple bedside nutritional assessments to quantify their requirements (e.g. the Royal Free Hospital nutritional prioritising tool score), including worked examples of how to calculate BMI in patients with ascites and measures of muscle mass using mid arm circumference, and clear tables summarising the nutritional content of commonly available supplement drinks together with target daily requirements. There are also tips on basic dietary advice we can give our patients in the clinic. For the decompensated phase, helpful pointers on managing nutrition in the context of hepatic encephalopathy (NOT protein restriction) and building up a rehabilitation exercise programme are also provided.

Ultimately, this article provides the basic tools to help us manage nutrition more effectively in these patients, and particularly for those without dedicated dieticians at their disposal this will be of great value. For any comments, do respond below, or send us a tweet @FrontGastro_BMJ.

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