Consensus Statement
Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver

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Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

Section snippets

Mechanism and etiology of malnutrition in cirrhosis

Malnutrition in cirrhosis is multifactorial and may be due to inadequate dietary intake, poor absorption or metabolic disturbances. Dietary intake can be decreased due to nausea, vomiting or early satiety secondary to ascites, gastroparesis, active alcoholism, reduced palatability due to salt restriction, aphthous ulcers secondary to vitamin B complex deficiency, dysgeusia secondary to zinc deficiency and poor socio-economic status especially in the developing countries. Restriction of oral

Assessment of nutritional status in cirrhosis

BMI is an inaccurate tool for nutritional assessment in patients with cirrhosis in the presence of ascites and oedema.

Common misconceptions in dietary advice in cirrhosis

There are several myths regarding pathogenesis and treatment of malnutrition in cirrhosis. For more than half a century, protein restriction has been one of the main treatments for HE.151, 152, 153 Older clinical observations had been reported that high protein intake may worsen encephalopathy in patients with cirrhosis154, and it had become a universal practice to recommend low-protein diet to patients with cirrhosis. More recent studies have, however, shown that protein restriction has no

Nutritional treatment options for hepatic encephalopathy

Malnutrition and sarcopenia directly play a significant role in development of recurrent and overt HE apart from predisposing patients to infections.55,84,239, 240, 241 Hence, the nutritional management options in HE should focus on prevention and/or delaying progression of sarcopenia, long-term ammonia-lowering drugs/dietary interventions and supplementation of micronutrient deficiencies. The pertinent questions for nutritional treatment options for HE are given below.

Nutrition in children with chronic liver disease

Poor nutrition is observed in up to 80% of children with CLD.293,294 Infants and those with severe cholestatic liver disease are at particularly high risk of malnutrition.

Growth failure is an important predictor of survival in children with CLD and therefore has been incorporated in the paediatric end-stage liver disease (PELD) scores. Nutritional assessment in children with CLD should include physical assessment for signs of nutrient deficiency, anthropometry and biochemical tests including

Conclusions

Assessing and treating malnutrition is an essential component of treating patients with CLD. Nutritional assessment and management can be improved by close cooperation between attending interns, medical residents, physicians, hepatologists, house staff and dieticians. Reuter et al.393 assessed the nutritional status in inpatients with cirrhosis using RFH-NPT and showed there was improvement in nutritional consultations after educational training regarding nutritional guidelines of the

CRediT authorship contribution statement

Pankaj Puri: Conceptualization, Methodology, Writing – original draft, Visualization. Radha K. Dhiman: Conceptualization, Methodology, Writing – original draft, Supervision. Sunil Taneja: Writing . Puneeta Tandon: Writing . Manuela Merli: Writing . Anil C. Anand: Writing . Anil Arora: Writing . Subrat K. Acharya: Writing . Jaya Benjamin: Writing . Yogesh K. Chawla: Writing . Sunil Dadhich: Writing . Ajay Duseja: Writing . C.E. Eapan: Writing . Amit Goel: Writing . Naveen Kalra: Writing .

Conflicts of interest

The authors have none to declare.

Funding

None.

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