EASL Clinical Practice Guidelines on nutrition in chronic liver disease

Sep 25, 2026

Liver cirrhosis commonly leads to malnutrition, which is linked to advancing liver failure and higher complication rates, including infections, hepatic encephalopathy, and ascites. The increasing prevalence of obesity and non-alcoholic steatohepatitis-related cirrhosis adds further risk, as malnutrition, obesity, and sarcopenic obesity can worsen prognosis and reduce survival. These European clinical practice guidelines review nutrition knowledge, detailing screening, assessment, and nutritional management principles, with targeted recommendations for specific clinical settings.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages22

Reading Time55 min

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Clinical Practice Guidelines JOURNAL OF HEPATOLOGY EASL Clinical Practice Guidelines on nutrition in chronic liver diseaseq 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 prevalence 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 cirrhotic patients. 􀀁 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 cirrhosis, occurring in 20–50% of patients. The progression of malnutrition 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 compensated cirrhosis and in more than 50% of patients with decompensated 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), malnutrition and muscle mass loss (sarcopenia), which has often been used as an equivalent of severe malnutrition,3 are associated with a higher rate of complications4 such as susceptibility to infections,5 hepatic encephalopathy (HE)6 and ascites, 4 as well as being independent predictors oflower survival in cirrhosis7,8 and in patients undergoing liver transplantation.9 Given 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@easlofﬁ[ce.eu](ce.eu). 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, amelioration of the nutritional status and muscle mass is not always achievable.10–12 Although the term ‘‘malnutrition” refers both to deﬁcienciesand to excesses in nutritional status, in the present CPGs ‘‘malnutrition” 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

FAQs

Why is nutritional monitoring important in chronic liver disease?

Malnutrition is frequent in cirrhosis and correlates with liver failure progression and complications such as infections, hepatic encephalopathy, and ascites. Nutritional status also impacts survival, so monitoring and intervention are crucial.

How do the guidelines describe malnutrition and related conditions?

The document treats malnutrition as undernutrition and notes that muscle mass loss (sarcopenia) is associated with adverse outcomes. It also highlights how obesity and sarcopenic obesity may coexist and worsen prognosis.

What topics and patient settings do the guidelines cover?

The guidelines examine screening, assessment, and management principles, with recommendations for hepatic encephalopathy, bone disease in cirrhotic patients, and care around liver surgery or transplantation, including critically ill cases.

Sep 25, 2026

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