Nutrition in advanced liver cirrhosis and perioperatively in liver transplantation

Liver cirrhosis leads to malnutrition as a serious complication through various mechanisms. Malnutrition occurs in up to over 50% of decompensated cirrhosis and significantly increases the risk of other complications such as ascites, hemorrhage, or hepatic encephalopathy. However, malnutrition is often undiagnosed or inadequately treated. It is often accompanied by a reduction in muscle mass, sarcopenia. Sarcopenic obesity is the simultaneous occurrence of sarcopenia and obesity. Body mass index is not a sufficient criterion for assessing nutritional status. In addition a detailed patient history, measurement of muscle mass, e.g., using upper arm circumference, bioimpedance analysis or abdominal wall muscles on CT or MRI, hand strength, and gait speed should be recorded. The liver frailty score can be used to assess the clinical status in liver cirrhosis. Therapy includes high-protein and high-calorie diet with a late meal. Long periods of fasting should be avoided. In addition, moderate exercise is recommended. It should be noted that physical activity can increase portal pressure. Malnutrition and sarcopenia on the liver transplant waiting list are associated with increased mortality before and after transplantation. The benefit of structured preoperative prehabilitation in terms of perioperative complications and survival has not yet been established, yet moderate physical activity before transplantation is encouraged, as daily activities may also have a beneficial effect on perioperative survival.