Advancing Nutritional Care in Cirrhosis and Cholestatic Liver Disease

ACG nutrition guidelines now recommend initiating enteral or oral nutrition early in hospitalized patients with cirrhosis to prevent gluconeogenesis-driven muscle wasting and related complications; feeding should begin promptly on admission when feasible.

This reverses older practice that favored delayed feeding and routine protein restriction. Current guidance removes routine protein limits and reframes dietary protein as a therapeutic tool to preserve lean mass—shifting care toward timely nourishment to reduce fasting-related sarcopenia and downstream morbidity.

Screen all admissions for malnutrition using validated tools such as Subjective Global Assessment or Nutrition Risk Screening, document baseline weight and anthropometry, involve a dietitian within 24 hours, and start oral supplementation or enteral nutrition when oral intake is inadequate to meet targets. Integrate feeding plans into daily rounds and monitor intake to avoid fasting intervals longer than 12 hours; early dietitian involvement and timely nutrition reduce catabolism and may improve outcomes.

Routine protein restriction is no longer recommended. Aim for roughly 1.2–1.5 g/kg/day with a plant-forward emphasis to limit ammonia production where possible. Practical options include legumes, soy, and dairy when tolerated; consider branched-chain amino acid supplementation for selected patients with persistent encephalopathy or intolerances. Structured feeding—frequent meals plus a late-night complex-carbohydrate or protein-containing snack—shortens the overnight fast and helps preserve muscle mass.

Operationalizing this requires a multidisciplinary nutrition protocol: standardize admission screening, automate dietitian referrals, document daily intake goals in the chart, and embed bedtime snacks and high-protein targets into order sets to shorten fasting intervals and preserve lean mass.