EASL Clinical Practice Guidelines on nutrition in chronic liver disease q European Association for the Study of the Liver* Summary A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising preva- lence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cir- rhotic patients. Ó 2018 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. Introduction Malnutrition is frequently a burden in patients with liver cirrho- sis, occurring in 20–50% of patients. The progression of malnutri- tion is associated with that of liver failure. While malnutrition may be less evident in patients with compensated cirrhosis it is easily recognisable in those with decompensated cirrhosis. Malnutrition has been reported in 20% of patients with compen- sated cirrhosis and in more than 50% of patients with decompen- sated liver disease. 1 Both adipose tissue and muscle tissue can be depleted; female patients more frequently develop a depletion in fat deposits while males more rapidly lose muscle tissue. 2,1 As detailed in these clinical practice guidelines (CPGs), mal- nutrition and muscle mass loss (sarcopenia), which has often been used as an equivalent of severe malnutrition, 3 are associ- ated with a higher rate of complications 4 such as susceptibility to infections, 5 hepatic encephalopathy (HE) 6 and ascites, 4 as well as being independent predictors of lower survival in cirrho- sis 7,8 and in patients undergoing liver transplantation. 9 Given these observations, malnutrition and sarcopenia should be recognised as complications of cirrhosis, which in turn worsen the prognosis of cirrhotic patients. Whether malnutrition can be reversed in cirrhotic patients is controversial. Although there is general agreement about the need to improve the dietary intake of these patients, by avoiding limitations and restrictions that are not evidence based, amelio- ration of the nutritional status and muscle mass is not always achievable. 10–12 Although the term ‘‘malnutrition” refers both to deficiencies and to excesses in nutritional status, in the present CPGs ‘‘mal- nutrition” refers to ‘‘undernutrition”. More recently, in addition to undernutrition, overweight or obesity are increasingly observed in cirrhotic patients because of the increasing number of cirrhosis cases related to non-alcoholic steatohepatitis (NASH). Muscle mass depletion may also occur in these patients, but due to the coexistence of obesity, sarcopenia might be overlooked. Obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis. 13–15,3 No previous guidelines released by the European Association for the Study of Liver Disease (EASL) have dealt with nutrition in advanced liver disease and/or have evaluated the relationship between nutritional status and the clinical outcome of patients. Therefore, the EASL Governing Board has asked a panel of experts in the field of nutrition and hepatology to produce the present CPGs. Methodology The panel initially established the most relevant questions to answer, considering relevance, urgency and completeness of the topics to be covered. The main questions addressed were: How can nutritional problems be recognised? In which condi- tions are nutritional assessments recommended? What are the available methods of evaluation? What are the consequences of malnutrition and its correction? Different clinical scenarios have been considered with special attention paid to nutrition in HE and before and after liver transplantation. A section devoted to bone metabolism in chronic liver disease has also been included. Each expert took responsibility and made pro- posals for statements for a specific section of the guideline. The literature search was performed in different databases (PubMed, Embase, Google Scholar, Scopus) and a list of perti- nent articles was derived from this ‘‘first line” search The initial key words were: ‘‘Nutrition” OR ‘‘Nutritional status” OR ‘‘Mal- nutrition” OR ‘‘Sarcopenia” AND ‘‘Liver cirrhosis” OR ‘‘Chronic liver Disease”. Further, more specific key words were also uti- lised: ‘‘nutritional assessment”, ‘‘nutrition risk”, ‘‘hepatic Journal of Hepatology 2018 vol. xxx j xxx–xxx q Clinical Practice Guideline Panel: Chair: Manuela Merli, EASL Governing Board representative: Annalisa Berzigotti, Panel members: Shira Zelber-Sagi, Srinivasan Dasarathy, Sara Montagnese, Laurence Genton, Mathias Plauth, Albert Parés. ⇑ Corresponding author. Address: European Association for the Study of the Liver (EASL), The EASL Building – Home of Hepatology, 7 rue Daubin, CH 1203 Geneva, Switzerland. Tel.: +41 (0) 22 807 03 60; fax: +41 (0) 22 328 07 24. E-mail address: easloffice@easloffice.eu. JOURNAL OF HEPATOLOGY Clinical Practice Guidelines Please cite this article in press as: EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol (2018), https://doi.org/10.1016/j.jhep.2018.06.024