Cirrhosis nutrition therapy

Cirrhosis nutrition therapy plays a crucial role in supporting liver function and addressing the metabolic changes that accompany disease progression. Cirrhosis is a progressive condition where scar tissue replaces healthy liver tissue and inhibits normal liver function. Scar tissue blocks the flow of blood and oxygen through the liver, which slows the liver’s ability to process blood, metabolize nutrients, and filter toxins. As cirrhosis worsens, the liver begins to fail.  

Chronic liver disease and cirrhosis are the 10th leading cause of death in the United States. It is estimated that 4.5 million adult Americans are diagnosed with liver disease. There are no treatments that can reverse liver damage or fully restore liver function in cirrhosis. While transplantation may be an option for some individuals, this blog will focus on nutrition management for those who have not undergone transplantation.  

The most common causes of cirrhosis include alcohol-associated liver diseases, metabolic dysfunction-associated steatohepatitis (formerly referred to as non-alcoholic fatty liver disease), and chronic infection with hepatitis C or hepatitis B viruses. 

Some individuals with cirrhosis experience no early symptoms until significant liver damage occurs. Others may experience early signs, such as poor appetite, unintentional weight loss, nausea, vomiting, tiredness, weakness, itchy skin, muscle cramps, and/or abdominal pain. As liver function declines, additional symptoms may arise, including bruising/bleeding easily, confusion, memory loss, personality changes, edema of the lower extremities, swelling of the abdomen from a buildup of fluid (ascites), severe itchy skin, internal bleeding, yellowing of the skin (jaundice), and/or dark color urine.  

Malnutrition  

While there are varied results on the specific prevalence of malnutrition in this patient population, it is estimated that nearly 50% of individuals with cirrhosis are malnourished. Inadequate oral intake results from many factors, including nausea, vomiting, dysgeusia (altered taste), early satiety, and diet unpalatability.

This patient population is commonly underdiagnosed with malnutrition due to complications of liver disease, such as fluid accumulation (edema and/or ascites), which makes it more challenging to assess weight changes or detect signs of muscle or fat loss. 

Assessing patients for malnutrition is especially important, as malnutrition is an independent predictor of clinical outcomes for patients with liver disease. Furthermore, malnutrition is associated with an increased risk of morbidity, mortality, biochemical dysfunction, compromised immune function, respiratory function, and delayed wound healing.  

Cirrhosis nutrition therapy focuses on addressing nutritional concerns to help improve quality of life and clinical outcomes. Consider the following nutrition management strategies for adults with cirrhosis. 

Energy needs 

Cirrhosis is a catabolic condition, increasing energy expenditure and thus raising the energy needs of this population. Increased energy intake has been shown to improve survival in patients with cirrhosis. 

Calorie needs should be individualized to the patient. When possible, indirect calorimetry should be used to measure a patient’s resting energy expenditure, providing a personalized nutrition prescription. In the absence of indirect calorimetry, consider the use of a weight-based equation. Apply clinical judgment, with 30–35 kcal/kg/day as a general rule of thumb for non-obese patients. An estimated dry weight may be necessary for this patient population to facilitate the calculation of needs and assessment of anthropometrics. 

Increased protein needs  

Patients with cirrhosis also have higher protein needs due to elevated protein turnover and catabolism. This heightened metabolic state can lead to muscle loss in some individuals. Providing a high-protein diet helps preserve muscle mass and reduces the risk of malnutrition. 

The current protein recommendation for adults with cirrhosis is 1.2 – 1.5 g/kg/day. 

This recommendation also extends to cirrhotic patients with hepatic encephalopathy (HE). Historically, it was recommended to restrict protein during HE. However, this recommendation is no longer supported by the most recent evidence-based guidelines.

Frequent meals and snacks 

The timing of nutritional intake is crucial for patients with cirrhosis, as the condition alters the way the body stores and utilizes nutrients for energy. Thus, a prolonged period of fasting should be avoided. Instead, small, frequent meals every 3–4 hours while awake are recommended.  

This topic can also be discussed in the context of early satiety, which is often associated with ascites. Additionally, an early breakfast and/or late-evening snack is recommended to help patients with cirrhosis maintain muscle mass.  

Sodium restriction 

Patients with cirrhosis are advised to limit their sodium consumption to control excessive fluid accumulation. Ascites, excessive fluid that develops within the peritoneal cavity, is the most common complication of cirrhosis. 50% of individuals with decompensated (advanced stage) cirrhosis develop ascites within 10 years of diagnosis.  

Sodium helps regulate fluid balance in the body by attracting water. Because it contributes to fluid buildup, patients with cirrhosis are advised to limit sodium intake to less than 2,000 mg per day.  

Sodium restriction may reduce the palatability of food, presenting a possible barrier to adequate nutrition intake. When patients are prescribed a sodium‐restricted diet, it is crucial to provide educational resources that offer suggestions to improve diet palatability, such as the following ways to enhance flavor:  

• Citrus (lemon or lime) 
• Vinegar 
• Fresh herbs  
• Sodium-free spice blends 

For patients with elevated potassium, it is recommended to avoid potassium-containing salt substitutes. It is essential to assess how sodium restrictions affect a patient’s ability to meet their increased energy and protein needs. Ongoing assessment of the patient’s fluid status, energy, and protein intake should be used to provide appropriate education and nutrition interventions. 

Fluid restriction 

While sodium restriction is the first-line treatment for patients with volume overload, fluid restriction may be indicated in individuals with cirrhosis who have severe hyponatremia (serum sodium <125 mEq/L). As the dietitian, it is essential to identify if a patient is on a fluid restriction and, if so, ensure nutrient needs are met within the limited fluid allowance.  

Micronutrient deficiencies 

In addition to impaired nutrient intake, malabsorption is common in patients with cirrhosis. These factors increase the risk of developing micronutrient deficiencies. Given the potential impacts of cirrhosis, the “Malnutrition, Frailty, and Sarcopenia in Patients with Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases” recommended that micronutrient deficiencies be assessed at least annually, repleted as indicated, and reassessed after repletion.  

Several deficiencies are particularly relevant in this population. For patients with alcohol-associated liver disease, specific nutrients of concern include folate, thiamine, zinc, selenium, vitamin D, and vitamin E.  

For patients with cholestatic liver disease, fat-soluble vitamin deficiencies (vitamins A, D, E, and K) are common due to impaired bile flow, which affects absorption. Vitamin D, zinc, and magnesium deficiencies may be of particular importance due to their association with reduced muscle strength, frailty, and/or sarcopenia.  

Conclusion  

Nutrition therapy is a key part of managing cirrhosis. Providing early personalized nutrition care focused on energy, protein, sodium, fluid, micronutrients, and meal timing helps prevent complications and supports liver function. Dietitians play a major role in making a lasting impact on the health of patients with cirrhosis.  

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References

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Smith A, Baumgartner K, Bositis C. Cirrhosis: Diagnosis and management. American Family Physician. 2019;100(12):759-770. https://www.aafp.org/pubs/afp/issues/2019/1215/p759.pdf. Accessed May 19, 2025.  

Chronic Liver Disease and Cirrhosis. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/liver-disease.htm. Last reviewed November 2023. Accessed May 23, 2025. 

Nutrition Care Manual. Cirrhosis (2021) Overview. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=275019&lv3=275020&ncm_toc_id=275020&ncm_heading=Nutrition%20Care. Accessed May 22, 2025.  

Traub J, Reiss L, Aliwa B, Stadlbauer V. Malnutrition in patients with liver cirrhosis. Nutrients. 2021;13(2):540. https://doi.org/10.3390/nu13020540. Accessed May 19, 2025.  

Hiejina M, Kudaravalli P, Samant H. Ascites. Updated 2023 Aug 8. In: StatPearls Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470482. Accessed May 23, 2025.  

Kwong AJ, Norman J, Biggins SW. Management of ascites and volume overload in patients with cirrhosis. Clin Liver Dis (Hoboken). 2024 Feb 9;23(1). https://doi.org/10.1097/CLD.0000000000000115. Accessed May 19, 2025. 

Kumar R, Marrapu S. Dietary salt in liver cirrhosis: with a pinch of salt! World J Hepatol. 2023;15(10):1084-1090. https://doi.org/10.4254/wjh.v15.i10.1084. Accessed May 19, 2025.  

Lai JC, Tandon P, Bernal W, et al. Malnutrition, frailty, and sarcopenia in patients with cirrhosis: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(3):1611–1644. https://doi.org/10.1002/hep.32049. Accessed May 19, 2025. 

Bischoff SC, Bernal W, Dasarathy S, et al. ESPEN practical guidance: Clinical nutrition in liver disease. Clin Nutr ESPEN. 2020;39:3353-3562. https://doi.org/10.1016/j.clnu.2020.09.001