Malnutrition, Frailty, and Sarcopenia in Patients with Cirrhosis

Patient Guideline Summary

Publication Date: July 7, 2021
Last Updated: March 3, 2023



This patient summary means to discuss key recommendations from the American Association for the Study of Liver Diseases for malnutrition, frailty, and sarcopenia in patients with cirrhosis. It is limited to adults 18 years of age and older and should not be used as a reference for children.



  • Cirrhosis refers to scar tissue in an organ, commonly the liver.
  • Common causes of liver cirrhosis are long-standing alcohol intake, hepatitis and fatty liver disease.
  • Cirrhosis can lead to malnutrition, frailty, and sarcopenia (loss of muscle mass).
  • This patient summary focuses on managing malnutrition, frailty, and sarcopenia due to cirrhosis of the liver.



All patients with cirrhosis should, if possible, be monitored:
  • for frailty with standardized tool at last annually.
  • for sarcopenia as frequently as every 8–12 weeks with objective measures such as the skeletal muscle index (SMI), computerized tomography (CT) or assessment of muscle contractile function. magnetic resonance imaging (MRI) may also be used.
  • for testosterone levels at baseline.



All patients with cirrhosis should receive:
  • counseling on the risks and adverse clinical consequences of frailty.
  • education, motivation, and behavioral skills support to reduce their risk of developing or worsening these conditions (primary prevention).
  • physical activity–based interventions to improve muscle contractile function and muscle mass.
    • Activity-based interventions in patients with cirrhosis should include:
      • assessing and reassessing frailty and/or sarcopenia using standardized tools
      • recommending a combination of aerobic and resistance exercises, and
      • tailoring recommendations based on assessments.

A positive frailty or sarcopenia screen should prompt:
  • evaluation for underlying etiologic risk factors.
  • a personalized management plan that includes calorie needs (secondary prevention).
    • Indirect calorimetry should be used to measure the patient’s resting energy expenditure (REE).
    • In the absence of indirect calorimetry, the following may be used:
      • Traditional predictive equations, such as the Harris-Benedict equation
      • Weight-based equations (using ideal body weight)
        • Nonobese—target of at least 35 kcal/kg body weight/day
        • Obese (nonhospitalized, clinically stable)—use of caloric targets stratified by BMI: 25–35 kcal/kg/day for individuals with BMI 30–40 kg/m2 and 20–25 kcal/kg/day for individuals with BMI ≥40 kg/m2.
    • Recommended protein intake for adults with cirrhosis is 1.2–1.5 g/kg ideal body weight per day. If critically ill, a target of 1.2–2.0 g/kg ideal body weight per day is recommended.
    • For children with chronic liver disease, recommended protein intake is up to 4 g/kg ideal body weight per day.
    • A diverse range of protein sources, including vegetable and dairy products, should be encouraged.
    • Protein intake should not be restricted in patients with hepatic encephalopathy (HE) (mental deficiencies due to liver disease).
    • Fasting time should be minimized, with a maximum interval of 3–4 hours between nutritional intake while awake, an early breakfast and/or late-evening snack.
    • Micronutrient deficiencies should be assessed at least annually, repleted if deficient, and reassessed after repletion.
  • (If not improving) a more intensive nutrition and exercise rehabilitation under the direct supervision of a registered dietician and certified exercise physiologist/physical therapist (tertiary prevention).
  • In patients who cannot meet nutritional targets on a sodium-restricted diet, liberalization of sodium restriction should be considered.
  • Enteral nutritional supplementation may be considered to achieve targets, but percutaneous gastrostomy tube (a feeding tube inserted surgically through the a bdominal wall into the stomach) should not be placed in a patient with cirrhosis and ascites.
  • Management should involve a multidisciplinary team:
    • Ideally, the patient’s primary care provider, gastroenterologist/ hepatologist, registered dietician, certified exercise physiologist/physical therapist, and health behavior specialist.
    • At least a registered dietician and certified exercise physiologist/physical therapist.

To manage malnutrition, frailty and sarcopenia, diagnosis and treatment is recommended for:
  • inflammatory conditions that lead to cirrhosis – such as hepatitis C virus (HCV), insulin resistance, obesity, and alcohol use disorder.
  • cirrhosis-specific complications (e.g., HE, ascites).

Management of obesity in a patient with decompensated cirrhosis should be supervised by a multidisciplinary team.
  • Target protein and physical activity are required to reduce the loss of muscle contractile function and muscle mass that can occur with weight loss.

In-hospital management:
  • Hospitalized patients should receive formal consultation with a registered dietician within 24 hours of admission.
    • If not available, assess for malnutrition using the Royal Free Hospital Nutrition Prioritizing Tool (RFH-NPT).
  • Oral nutritional supplementation is the first-line therapy.
  • Fasting periods and frequency of Nothing by Mouth (NPO) orders should be minimized.
  • Precautions should be taken to reduce risk of aspiration and development of hyperglycemia.
  • Enteral nutritional supplementation should be considered to achieve targets.
    • Close monitoring is warranted for signs of rebleeding if an enteric tube is required after recent banding of esophageal varices.
  • Parenteral nutritional should be reserved for patients who are intolerant of enteral nutrition.
  • Testosterone replacement may be considered in select men with low testosterone to improve muscle mass.
    • Relative contraindications to use of testosterone include a history of hepatocellular carcinoma (HCC) (cancer), other malignancy or thrombosis.

Transjugular intrahepatic portosystemic shunt (TIPS) placement for standard indications (e.g., ascites, acute variceal bleeding) may offer an indirect benefit of improving muscle mass.

Liver transplantation cannot be recommended specifically for the treatment of frailty or sarcopenia, but frailty or sarcopenia should not prevent liver transplantation.


  • AASLD: American Association For The Study Of Liver Diseases
  • BMI: Body Mass Index
  • CT: Computerized Tomography
  • HCC: Hepatocellular Carcinoma
  • HCV: Hepatitis C Virus
  • HE: Hepatic Encephalopathy
  • MRI: Magnetic Resonance Imaging
  • NPO: Nothing By Mouth
  • REE: Resting Energy Expenditure
  • RFH-NPT: Royal Free Hospital Nutrition Prioritizing Tool
  • SMI: Skeletal Muscle Index
  • TIPS: Skeletal Muscle Index

Source Citation

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.


The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.