ESPEN guideline on clinical nutrition in liver disease Mathias Plauth a, * , William Bernal b , Srinivasan Dasarathy c , Manuela Merli d , Lindsay D. Plank e , Tatjana Schütz f , Stephan C. Bischoff g a Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany b Institute of Liver Studies, King's College Hospital, London, United Kingdom c Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA d Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy e Department of Surgery, University of Auckland, Auckland, New Zealand f IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany g Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany article info Article history: Received 14 December 2018 Accepted 18 December 2018 Keywords: Sarcopenia Acute liver failure Fatty liver disease Alcoholic steatohepatitis Cirrhosis Transplantation summary This update of evidence-based guidelines (GL) aims to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal nutritional and metabolic management of adult patients with liver disease. The GL was commissioned and financially supported by ESPEN. Members of the guideline group were selected by ESPEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. A total of 85 recommendations were made for the nutritional and metabolic management of patients with acute liver failure, severe alcoholic steatohepatitis, non-alcoholic fatty liver disease, liver cirrhosis, liver surgery and transplantation as well as nutrition associated liver injury distinct from fatty liver disease. The recommendations are preceded by statements covering current knowledge of the under- lying pathophysiology and pathobiochemistry as well as pertinent methods for the assessment of nutritional status and body composition. © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved. 1. Introduction The prognostic and therapeutic role of nutritional issues in the management of patients with liver disease has been known for long [1] and therefore, nutritional status was one of the variables in the original prognostic score devised by Child and Turcotte [2]. Since publication of the first ESPEN guidelines (GL) on nutrition in liver disease [3] and the subsequent updates [4,5] a considerable body of new evidence has accumulated necessitating an update of the GL. In the past twenty years new methods for the assessment of nutritional status and the recognition of the prognostic role of sarcopenia are just two among many other major achievements which are covered in the updated ESPEN GL that is based on the current ESPEN guideline methodology [6]. In recognition of the increasing disease burden from non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH) the current GL hold a new chapter addressing the nutritional management of NAFL/NASH patients. Furthermore, a second new chapter addresses clinical questions arising from nutrition associated liver injury (NALI) distinct from NAFL/NASH. In the current guidelines' working group experts from three global regions (Europe, America, Australasia) could base their work on the current GL of the German Society for Nutritional Medicine [7] implementing the identical methodology. The aim of the current GL is to translate current evidence and expert opinion into recommendations for multidisciplinary teams responsible for the optimal metabolic management of patients with liver disease. 1.1. Target population This GL is aimed to address clinically relevant issues in the nutritional and metabolic management of adult patients with liver disease. * Corresponding author. E-mail address: mathias.plauth@klinikum-dessau.de (M. Plauth). Contents lists available at ScienceDirect Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu https://doi.org/10.1016/j.clnu.2018.12.022 0261-5614/© 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved. Clinical Nutrition xxx (xxxx) xxx Please cite this article as: Plauth M et al., ESPEN guideline on clinical nutrition in liver disease, Clinical Nutrition, https://doi.org/10.1016/ j.clnu.2018.12.022