Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis
Publication Date: July 7, 2021
Last Updated: March 14, 2022
Guidance statements
1. All patients with cirrhosis should be assessed for frailty with a standardized tool both at baseline and
longitudinally.
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.
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.
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
transplantation.
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
nutritional status.
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
nutrition.
20. Calorie needs should be personalized to the patient.
longitudinally.
1a. There are insufficient data to recommend the use of one frailty tool over another. Instead, we
recommend that selection of the standardized frailty tool in clinical practice should depend upon
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)
assessment.
2. All patients with cirrhosis should be counseled on the risks and adverse clinical consequences of frailty
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)
assessment.
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.
4a. There are currently insufficient data to support a bedside tool to assess 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.
5. Because of the risk of exposure to radiation, use of abdominal CT solely for the purpose of muscle mass
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.
6a. Frailty testing may be particularly useful in the ambulatory setting and when intermediate-term
and long-term longitudinal assessments are needed to assess natural progression or response to
treatment.
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).
7. In research studies of patients with cirrhosis, including clinical trials evaluating interventions related to
and long-term longitudinal assessments are needed to assess natural progression or response to
treatment.
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
transplantation.
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
nutritional status.
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
nutrition.
20. Calorie needs should be personalized to the patient.
20a. When possible, indirect calorimetry should be used to measure the patient’s resting energy
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:
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:
Traditional predictive equations, such as the Harris-Benedict equation
Weight-based equations (using ideal body weight)
Weight-based equations (using ideal body weight)
o Nonobese—target of at least 35 kcal/kg body weight/day
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
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
20c. In patients who screen positive for frailty or sarcopenia and cannot meet nutritional targets on a
sodium-restricted diet, liberalization of sodium restriction should be considered to facilitate
sodium-restricted diet, liberalization of sodium restriction should be considered to facilitate
adequate oral intake.
21. Recommended daily protein intake for adults with cirrhosis is 1.2-1.5 g/kg ideal body weight per day.
i. For adults with cirrhosis who are critically ill, a target of 1.2-2.0 g/kg ideal body weight per day
is recommended.
ii. A diverse range of protein sources, including vegetable and dairy products, should be
encouraged.
iii. BCAA supplementation is not recommended beyond emphasizing the importance of meeting
daily overall protein targets from a diverse range of protein sources.
is recommended.
ii. A diverse range of protein sources, including vegetable and dairy products, should be
encouraged.
iii. BCAA supplementation is not recommended beyond emphasizing the importance of meeting
daily overall protein targets from a diverse range of protein sources.
22. For children with chronic liver disease, recommended daily protein intake should be up to 4 g/kg ideal
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
awake.
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
achieve targets.
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.
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
awake.
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
achieve targets.
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.
28a. Particular caution should be applied to prescribing weight loss in a patient with decompensated
cirrhosis.
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.
cirrhosis.
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.
29. All hospitalized patients with cirrhosis should receive formal consultation with a registered dietician within 24
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.
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.
32a. Precautions should be taken to reduce risk of aspiration and development of hyperglycemia.
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.
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.
33. In patients who are critically ill with cirrhosis, a higher protein target of 1.2-2.0 g/kg ideal body weight per day
is recommended.
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
repletion.
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
at baseline.
39. Testosterone replacement may be considered in select men with low testosterone to improve muscle mass.
is recommended.
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
repletion.
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
at baseline.
39. Testosterone replacement may be considered in select men with low testosterone to improve muscle mass.
39a. Relative contraindications to use of testosterone include a history of HCC, other malignancy, or
thrombosis.
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Recommendation Grading
Overview
Title
Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis
Authoring Organization
American Association for the Study of Liver Diseases
Publication Month/Year
July 7, 2021
Last Updated Month/Year
August 14, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Dietician nutritionist, physician, social worker, nurse, nurse practitioner, physician assistant
Scope
Assessment and screening, Management
Diseases/Conditions (MeSH)
D008103 - Liver Cirrhosis, D044342 - Malnutrition, D000073496 - Frailty, D055948 - Sarcopenia
Keywords
frailty, cirrhosis, malnutrition, Sarcopenia
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.