Malnutrition in cirrhosis: More food for thought

Table 1 Strategies to treat malnutrition in cirrhosis

Nutritional recommendations
Small, frequent meals and snacks (5-7 per day)
High calorie intake (≥ 32 kcal/kg/d)
High protein intake (1.2-1.5 g/kg/d)
Late evening snack containing protein and carbohydrate
Add oral nutrition supplements when unable to meet energy-protein requirements via ad-libitum dietary intake
Low sodium diet (≤ 2000 mg/d) if ascites or oedema present
Supplement with branched chain amino acids (25%-30% of total protein requirement) if hepatic encephalopathy or sarcopenia present, whilst ensuring overall protein intake meets requirements
Initiate enteral feeds (nasogastric) if unable to meet energy-protein needs via oral diet (polymeric, energy-dense formula). Consider nasojejunal tube if severe gastroparesis or intolerance of nasogastric feeds
Initiate parenteral nutrition if malnourished and enteral route either not accessible or unable to tolerate full energy-protein requirements