Enteral energy and macronutrients in end-stage liver disease

Protein-energy malnutrition is the most common comorbidity affecting adults and children with end-stage liver disease. Despite clear evidence linking malnutrition to poor outcomes before and after liver transplantation, nutrition rehabilitation is often inadequately emphasized in the clinical management of these patients. The primary aim of this review is to synthesize the available evidence supporting the current clinical guidelines on enteral nutrition support and, more important, to highlight the lack of evidence behind much of what is considered "standard of care" for the nutrition management of patients with cirrhosis. In addition, the mechanisms of malnutrition are reviewed, the limitations of tools used to assess body composition in this setting are discussed, and the differences in macronutrient metabolism between healthy subjects and patients with end-stage liver disease are explained. A summary of recommendations is provided.