Summary

Sarcopenia and malnutrition in liver disease worsen prognosis in patients. The following guidelines provide physicians with a multi-disciplinary approach to assess and treat sarcopenia with special focus on overcoming nutritional deficiencies.

In India, about 1 million patients are diagnosed with liver cirrhosis every year. Cirrhosis in India accounts for a standardised death rate of 23.6 per 100,000 population, and 2% of deaths due to all causes. 20 to 50% of patients with liver cirrhosis are found to experience malnutrition and muscle mass loss (sarcopenia), resulting in reduced survival rates.

The European Association for the Study of Liver Disease (EASL) Clinical Practice Guidelines have been developed to provide physicians with an approach to sarcopenia in patients with liver cirrhosis. The recommendations include:

Screening and counselling

1. A rapid nutritional screening followed by a more detailed nutritional assessment preferably by a registered dietitian or nutrition expert in those with detected malnutrition risk during screening.
2. Cirrhotic patients with malnutrition should undergo nutritional counselling by a multidisciplinary team to help patients reach an adequate caloric and protein intake.

• 35 kcal/kg actual BW/d (in non-obese individuals) is the minimum cut-off for optimal daily energy intake
• 1.2 to 1.5 g/kg actual BW/d is the minimum cut-off for optimal daily protein intake

Supplementation

1. Malnourished decompensated cirrhotic patients should have late evening oral nutritional supplementation and breakfast in their dietary regimen.
2. When adequate nitrogen intake is not achieved by oral diet BCAA supplements and leucine enriched amino acid supplements should be considered in decompensated cirrhotic patients.
3. A period of enteral nutrition is recommended in patients with malnutrition and cirrhosis who are unable to achieve adequate dietary intake with the oral diet (even with oral supplements).

Weight loss

1. Whenever possible, patients with cirrhosis can be encouraged to prevent and/or ameliorate sarcopenia by avoiding hypomobility and progressively increasing physical activity.
2. To obtain progressive weight loss (>5 to 10%), a nutritional and lifestyle programme should be implemented in obese cirrhotic patients with a BMI >30 kg/m² (corrected for water retention).
3. Obese cirrhotic patients should get a tailored, moderately hypocaloric (-500 to 800 kcal/d) diet, with adequate protein intake (>1.5 g proteins/kg ideal BW/d) for achieving weight loss (>5 to 10%) without compromising on protein.

Assessment of vitamin intake and deficiency

1. Micronutrients and vitamins should be administered for treating confirmed or clinically suspected deficiency in cirrhotic patients.
2. Cirrhotic patients should have their vitamin D levels assessed because deficiency is highly prevalent and this can adversely affect clinical outcomes
3. Oral vitamin D supplements should be given to cirrhotic patients if their vitamin D levels are <20 ng/ml with a goal to reach a target serum vitamin D (25(OH)D) of >30 ng/ml.

Sodium intake

Since diet palatability may cause a reduction in caloric intake in cirrhotic patients with ascites under sodium restriction, care must be taken to meet the recommended intake of sodium ∼80 mmol day = 2 g of sodium corresponding to 5 g of salt added daily to the diet.

Bone mass density

1. Patients with cirrhosis, cholestatic liver diseases, those on long-term corticosteroid treatment, and before liver transplantation must have their BMD checked.
2. Osteoporosis and osteopenia should be diagnosed by lumbar and femoral densitometry (DEXA) whereas vertebral fractures should be diagnosed by doing lateral X-rays of the dorsal and lumbar spine.
3. Patients within normal BMD should have a repeat DEXA after two to three years. However, if and when rapid bone loss is seen, this can be done within one year.
4. Patients with chronic liver disease and a T-score below -1.5 should get supplements of calcium (1,000–1,500 mg/d) and 25(OH)D (400–800 IU/d or 260 µg every two weeks)
5. Cirrhotic patients with osteoporosis, and, patients waiting for liver transplantation should get bisphosphonates.

Hormone supplementation

In males with hemochromatosis and hypogonadism, testosterone supplementation and venesection should be considered.

Considerations for surgery

1. Cirrhotic patients listed for transplantation or scheduled for elective surgery, should be screened for malnutrition and sarcopenia. Sarcopenia treatment leads to an improvement in body protein status and clinical outcomes and should be done before elective surgery.
2. To identify which obese cirrhotic patients being considered for surgery are at a higher risk of morbidity and mortality, sarcopenic obesity screening with body composition analysis should be done.
3. A total energy intake of 30 kcal/kg.BW/d and a protein intake of 1.2 g/kg.BW/d should be given preoperatively to maintain nutritional status, whereas to improve nutritional status a total energy intake of 35 kcal/kg.BW/d and a protein intake of 1.5 g/kg.BW/d should be given preoperatively.
4. Since specialised regimens (e.g. BCAA-enriched, immune-enhancing diets) do not seem to improve morbidity or mortality in intervention trials, standard nutrition regimens are recommended for preoperative nutrition.
5. To reduce infection rates, normal food and/or enteral tube feeding should be started early, or within 12 to 24 hours post liver transplantation.
6. Instead of no feeding, parenteral nutrition should be used in order to reduce complication rates, time on mechanical ventilation and ICU stay when oral or enteral nutrition is not possible or practical.
7. An energy intake of 35 kcal/kg.BW/d and a protein intake of 1.5 g/kg.BW/d should be given after the acute postoperative phase.
8. Chronic liver disease patients can be managed as per the ERAS protocol after other surgical procedures.

Nutrition in hospitalised and critically ill patients

1. In patients with unprotected airways, and in HE patients when their cough and swallow reflexes are compromised, parenteral nutrition is considered if enteral nutrition is contraindicated or impractical.
2. In obese patients, a reduced target energy intake (25 kcal/kg.BW/d) and an increased target protein intake (2.0 g/kg.BW/d) is met with enteral tube feeding and/or parenteral nutrition.
3. All critically ill cirrhotic patients should be considered for their nutritional status and the presence of sarcopenia. They should be treated for manifestations of severe decompensation and get nutritional support also.
4. Critically ill cirrhotic patients unable to achieve adequate dietary intake by mouth should get supplement dietary intake via enteral nutrition, or via parenteral nutrition, if their oral diet or enteral nutrition is not tolerated or contraindicated.
5. Naso-gastroenteric tubes are indicated in patients with non-bleeding oesophageal varices.
6. PEG insertion in cirrhotic patients is best avoided due to the risk of bleeding.
7. Critically ill cirrhotic patients should have a daily energy intake of more than the recommended 35–40 kcal/kg.BW/d or 1.3 times the measured resting energy expenditure (REE).
8. Critically ill cirrhotic patients should have a daily protein intake of more than the recommended 1.2–1.3 g/kg.BW/d.
9. Critically ill cirrhotic patients do not have a morbidity or mortality benefit from the use of specialised regimens (e.g. BCAA-enriched, immune-enhancing diets) and therefore standard nutrition regimens can be used.
10. BCAA-enriched solutions should be used to facilitate resolution in critically ill cirrhotic patients with HE.
11. Nutritional support should be provided to accelerate the resolution of HE in cirrhosis and severe/acute alcoholic hepatitis, and to better the survival in patients with low-calorie intake.