Nutrition in cirrhosis: bridging guidelines and practice in hepatic disease

Undernutrition and sarcopenia are common in patients with cirrhosis and independently predict increased morbidity and mortality. Despite recent guidelines emphasizing nutritional intervention, implementation in clinical practice remains inconsistent. This review is informed by key guidelines including the 2025 ACG guidelines on malnutrition and perioperative management in cirrhosis and the 2024 AASLD practice guidance on acute-on-chronic liver failure, and supplemented by newer meta-analyses and reviews, linking evidence-based recommendations to practical patient care strategies.

The Royal Free Hospital Nutritional Prioritizing Tool is recommended for screening, with high sensitivity. Current recommendations for dietary intake include 35 kcal/kg/day and 1.2-1.5 g/kg/day of protein, with protein restriction contraindicated even in hepatic encephalopathy. Late evening snacks and micronutrient repletion (particularly vitamin D, zinc, and thiamine) show clinical benefit. Combined exercise and nutritional interventions demonstrate the greatest efficacy for improving sarcopenia.

While recent guidelines have clarified optimal nutritional strategies in cirrhosis, significant implementation gaps persist. Addressing barriers including clinician awareness, resource constraints, and access to specialized nutrition services is essential to improve outcomes in this high-risk population.