Malnutrition & Nutrition in Liver Disease

Sarcopenia assessment, meal timing, nighttime snack, protein guidance, enteral nutrition, BCAAs, and micronutrient management in cirrhosis — ACG 2025.

📖 4 Sections⏱ ~30 min✅ 3-question quiz

Malnutrition & Assessment

Prevalence, screening tools, sarcopenia

Malnutrition in Liver Disease

Malnutrition is a near-universal complication of advanced liver disease. It adversely affects mortality, hospitalization, waitlist outcomes, and post-transplant outcomes. ACG 2025 emphasizes routine nutritional screening and early intervention.

Micronutrient Deficiency

Isolated zinc, vitamin D, B12 deficiency common. May occur even in early liver disease.

Sarcopenia

Low skeletal muscle mass. Prevalence 30–70% in cirrhosis. Independent predictor of mortality and poor transplant outcomes.

Frailty

Reduced physical performance. Liver Frailty Index (LFI) predicts waitlist mortality. Treatable with nutrition + exercise.

Nutritional Screening & Assessment Tools

Royal Free Hospital-Global Assessment (RFH-GA)

Validated for cirrhosis. Combines BMI, mid-arm muscle circumference, dietary intake. Preferred screening tool.

Liver Frailty Index (LFI)

Grip strength + chair stands + balance. Best predictor of waitlist mortality. Modifiable with intervention.

Nutritional Risk Screening 2002 (NRS-2002)

Good for hospitalized patients. Simple 3-question screen. Escalate to full assessment if score ≥3.

Hand Grip Strength

Simple, reproducible sarcopenia proxy. Low grip = increased mortality risk. Easy to perform at bedside.

CT-measured muscle area (L3)

Research standard for sarcopenia. Psoas/skeletal muscle index at L3. Not routine but increasing use pre-transplant.

DEXA

Gold standard for body composition. Limited availability. Useful when sarcopenia diagnosis is uncertain.

Singal AK et al. ACG Clinical Guideline: Malnutrition and Nutritional Recommendations in Liver Disease. Am J Gastroenterol. 2025;120:950–972.