Background

The exponential rise in obesity and prevalence of alcohol misuse has resulted in liver disease becoming the third most common cause of death in the working-age population.1 A key aspect of managing patients with liver disease, from the stages of compensated cirrhosis through to liver failure, is early recognition and treatment of malnutrition. Malnutrition is defined as a deficiency or excess (or imbalance) of energy, protein and other nutrients and is most often associated with undernutrition.2 3 In cirrhosis, this is closely associated with a reduction in muscle mass, function and strength, known as sarcopenia.4 Collectively, malnutrition and sarcopenia negatively impact on a patients’ ability to complete daily tasks, quality of life, liver-related morbidity and mortality.1 5–10 Given the increasing prevalence of obesity, diabetes and their association with non-alcoholic fatty liver disease (NAFLD), an imbalance of nutritional intake is becoming increasingly observed in patients with cirrhosis.11 12 The resultant combination of adiposity and sarcopenia, termed ‘sarcopenic obesity’, poses unique nutritional challenges, with regard to optimising metabolic risk factors (ie, weight loss, glycaemic/lipid control) and muscle function.

Recently published guidelines by European Association for Studies of Liver (EASL)3 and European Society for Clinical Nutrition and Metabolism (ESPEN)13 provide comprehensive overviews of nutrition in cirrhosis. Herein, we provide a case-based practical guide of the causes of malnutrition, assessments tools, daily requirements and dietary interventions in both compensated and decompensated cirrhosis.

Case Part 1: compensated liver cirrhosis

A 49-year-old man, with NAFLD cirrhosis and portal hypertension, presented with fatigue, tiredness and unintentional weight loss (3 kg over 6 months). He had a past medical history of type 2 diabetes mellitus, hypertension and hyperlipidaemia. Current medications included Metformin 1 g two times per day, Amlodipine 10 mg one time per day and Atorvastatin 20 mg one time day. He never smoked and drank 0–2 units of alcohol …