Table 2.

Summary of Nutritional Recommendations for Liver Transplant Candidates and Recipients.

Liver transplant candidate

•Perform nutritional screening of all ESLD patients using RFH-NPT at baseline. • Detailed nutritional assessment if: ➢ BMI ≤18.5 kg/m2 or CTP class C ➢ Detected at-risk of malnutrition on nutritional screening •Include SMI-L3 assessment to quantify muscle mass when CT performed for other indications. •Hand-grip strength and gait speed should be used to assess muscle strength and performance. •Utilize local population-based cut-offs. • Dietary recommendation ➢ Provide calories up to 1.2–1.3 times the REE (use indirect calorimetry, if available) ➢ Total calories: 35–40 kcal/kg/day, 60–70% carbohydrates and 20–30% proteins. ➢ BMI based calorie supplementation should be considered in obese. ➢ Multiple meals every 5–6 h with nocturnal calories dense snack (50 gm complex carbohydrates, 15 gm protein). ➢ While salt restriction is important in patients with ascites, palatability should not be compromised. ➢ Supplement vitamins and trace minerals. ➢ Oral BCAA can be considered in sarcopenic patients, patient with recurrent HE, or protein intolerance to meet daily protein requirements. •Prescribe graded, individualized exercise programs (aerobic and resistance) with a target of 150 min/week after assessing safety. •Minimize iatrogenic fasting for investigations/procedures. •Role of hormonal therapy and immune-nutrition supplementation remains unclear. • Periodically reassess nutrition and impact of interventions ➢ Annually in stable compensated cirrhosis ➢ Quarterly advanced/decompensated cirrhosis •In hospitalized critically ill cirrhosis patients, assess dietary intake daily and supplement using nasogastric feeding if unable to meet requirements orally.

Liver transplant recipients

•A detailed individualized nutritional plan should be made for all prospective liver transplant recipients beforehand.

Perioperative period

• Follow ERAS protocol pre-operatively ➢ Carbohydrate containing fluids pre-operatively to avoid accelerated starvation. •Initiate early enteral nutrition within 12–24 h post-operatively •Gradually up-titrate calorie and protein supplementation. •Parenteral nutrition is preferable to no nutrition when enteral nutrition is not feasible. •Standard nutrition formula should be used.

Long-term follow-up

•Monitor weight and body mass index during follow-up. •Ensure dietary compliance, exercise, restricted weight gain, and alcohol abstinence. •Monitor for sarcopenic obesity, diabetes, dyslipidaemia, hypertension, osteodystrophy, and other risks regularly. •Actively identify and manage immunosuppressant drugs related metabolic derangements and drug interactions.

ESLD, End-stage liver disease; RFH-NPT, Royal free hospital-Nutrition prioritizing tool; BMI, Body mass index; SMI, Skeletal muscle index; CT, Computed tomography; REE, Resting energy expenditure; BCAA, Branched chain amino acids; HE, Hepatic encephalopathy; ERAS, Enhanced recovery after surgery; PTMS, Post-transplant metabolic syndrome.