Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis
the relative need for efficiency versus objectivity of assessment within that clinical scenario. In
patients with compensated cirrhosis, annual frailty assessment may be sufficient, whereas
patients with decompensated cirrhosis may benefit from more frequent (every 3-6 months)
regardless of their baseline frailty status.
Given the strong and consistent association between muscle mass and outcomes in both adults and children
3. with cirrhosis, objective measures of muscle loss should be considered to assess risk for poor outcomes in
patients with cirrhosis.
4. SMI as assessed by CT image analysis is recommended as the most consistent and reproducible method to
quantify muscle mass in patients with cirrhosis.
4b. MRI measurement of skeletal muscle mass has not been validated in patients with cirrhosis but
theoretically provides the same information on muscle mass as CT imaging.
measurement is not recommended for routine use, but quantification of skeletal muscle mass should be
considered when an abdominal CT is obtained as part of clinical care or in patients in whom assessment of
muscle contractile function is not practical or feasible (e.g., acutely ill patients, very young children).
6. In clinical settings, we recommend systematic assessment of frailty and/or sarcopenia in all patients with
cirrhosis using a standardized instrument.
and long-term longitudinal assessments are needed to assess natural progression or response to
6b. Sarcopenia testing may be particularly useful for patients in whom administration of tests of
frailty are not feasible or are impractical (e.g., because of acute severe illness or inability to
participate in testing such as in very young children).
malnutrition and/or muscle dysfunction, we recommend assessment of both frailty and sarcopenia, when
possible, to more comprehensively capture the impact of interventions on these complementary endpoints.
8. All patients with cirrhosis should receive education, motivation, and behavioral skills support to reduce their
risk of development of these conditions (primary prevention).
9. A positive frailty or sarcopenia screen should prompt evaluation for underlying etiologic risk factors and the
development of an ambulatory personalized management plan (secondary prevention).
10. Reassessment of frailty or sarcopenia using the same standardized tool as baseline assessment should occur
at least annually for patients with well compensated disease but as frequently as every 8 to 12 weeks in
those with decompensated cirrhosis and/or those undergoing active management for these conditions.
11. Patients with progressive frailty or sarcopenia despite initiation of secondary prevention efforts should
undergo more intensive nutrition and exercise rehabilitation under the direct supervision of a registered
dietician and certified exercise physiologist/physical therapist (tertiary prevention).
12. Management should involve a multidisciplinary team consisting of the patient’s primary care provider,
gastroenterologist/hepatologist, registered dietician, certified exercise physiologist/physical therapist, and
health behavior specialist (if there is concurrent mental health condition) when possible. However, if not
available at all levels of prevention/health promotion, then at a minimum, referral to a registered dietician
and certified exercise physiologist/physical therapist is recommended at the tertiary preventive level.
13. Treatment of inflammatory conditions that lead to cirrhosis, such as HCV, insulin resistance, obesity,
and alcohol use disorder, is recommended to manage malnutrition, frailty, and sarcopenia.
14. Identification and management of cirrhosis-specific complications (e.g., HE, ascites) is recommended
in all patients with cirrhosis to manage malnutrition, frailty, and sarcopenia.
15. TIPS placement for standard indications (e.g., ascites, acute variceal bleeding) may offer an indirect
benefit of improving muscle mass.
16. In the absence of specific data on which patients will experience improvement in frailty and
sarcopenia posttransplant, liver transplantation cannot be recommended specifically for the
treatment of frailty or sarcopenia.
17. We do not recommend using frailty or sarcopenia as an absolute contraindication against liver
18. All patients with cirrhosis (regardless of a diagnosis of malnutrition) should receive educational resources
and counseling regarding the association between nutritional status and outcomes and to optimize
19. Patients with cirrhosis who screen positive for malnutrition risk, frailty, or sarcopenia should receive a
personalized intake “prescription” that is tailored to actual needs and incorporates individual habits around
20. Calorie needs should be personalized to the patient.
expenditure in order to provide a personalized intake prescription.
20b. In the absence of indirect calorimetry, data, although limited, support the use of the following:
Weight-based equations (using ideal body weight)
o Obese (nonhospitalized, clinically stable)—use of caloric targets stratified by
BMI: 25-35 kcal/kg/day for individuals with BMI 30-40 kg/m
sodium-restricted diet, liberalization of sodium restriction should be considered to facilitate
ii. A diverse range of protein sources, including vegetable and dairy products, should be
iii. BCAA supplementation is not recommended beyond emphasizing the importance of meeting
daily overall protein targets from a diverse range of protein sources.
body weight per day.
23. Protein intake should not be restricted in patients with HE.
24. Fasting time should be minimized, with a maximum interval of 3-4 hours between nutritional intake while
25. To minimize nocturnal fasting time, an early breakfast and/or late evening snack should be recommended.
26. In ambulatory patients with cirrhosis and children with cirrhosis/end-stage liver disease who do not meet
dietary intake requirements with oral intake, enteral nutritional supplementation may be considered to
27. Percutaneous gastrostomy tubes should not be placed in patients with cirrhosis and ascites.
28. If medically required, weight loss should be undertaken under the supervision of a multidisciplinary team.
28b. Intake of target protein and physical activity are required to reduce the loss of muscle contractile
function and muscle mass that can occur with weight loss.
hours of admission or, if not available, then assessment for malnutrition using the Royal Free Hospital-
Nutrition Prioritizing Tool.
30. Strategies to minimize this fasting period or frequency of NPO orders (e.g., pre-bedtime snack; early morning
snack if the procedure will be in the late afternoon; consider advancing diet rapidly when there is no indication
for NPO status) should be implemented.
31. Oral nutritional supplementation is the first-line therapy for hospitalized patients with cirrhosis who are
unable to meet energy needs via volitional intake alone.
32. In hospitalized patients with cirrhosis who are unable to meet energy needs with volitional intake and oral
nutritional supplementation, enteral nutritional supplementation should be considered to achieve targets.
32b. The presence of esophageal varices is not an absolute contraindication to placement of an enteric
feeding tube, but close monitoring is warranted for signs of rebleeding if enteric tube is required
after recent banding of esophageal varices.
32c. Parenteral nutritional should be reserved for patients with cirrhosis who are intolerant to enteral
nutrition and unable meet dietary intake requirements via oral intake alone.
34. In hospitalized patients with decompensated cirrhosis, parenteral nutritional support should be considered in
patients who are unable to meet nutritional requirements through oral intake alone and are unable to receive
enteral nutritional support.
35. Micronutrient deficiencies should be assessed at least annually, repleted if deficient, and reassessed after
36. Physical activity–based interventions are recommended to improve muscle contractile function and muscle
mass in patients with cirrhosis.
37. The three components to activity-based interventions in patients with cirrhosis should include 1) assessing
and reassessing frailty and/or sarcopenia using standardized tools, 2) recommending a combination of
aerobic and resistance exercises, and 3) tailoring recommendations based on assessments
38. In men with cirrhosis who may be candidates for testosterone therapy, testosterone levels should be checked
39. Testosterone replacement may be considered in select men with low testosterone to improve muscle mass.
Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis
July 7, 2021
Supplemental Implementation Tools
External Publication Status
Country of Publication
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Dietician nutritionist, physician, social worker, nurse, nurse practitioner, physician assistant
Assessment and screening, Management
D008103 - Liver Cirrhosis, D044342 - Malnutrition, D000073496 - Frailty, D055948 - Sarcopenia
frailty, cirrhosis, malnutrition, Sarcopenia
Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, Carey EJ. Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Sep;74(3):1611-1644. doi: 10.1002/hep.32049. Erratum in: Hepatology. 2021 Dec;74(6):3563. PMID: 34233031; PMCID: PMC9134787.