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KEY POINTS

Most often, patients with end-stage liver disease (ESLD) who are candidates for liver transplantation (LT) will present with significant malnutrition. Exceptions to the rule may be patients with acute etiologies (e.g., fulminant hepatic failure), but even those patients are expected to experience rapid deterioration of their nutritional status.1,2

Candidates for LT are evaluated by the transplant team’s selection committee after considering their medical, surgical, psychosocial, and nutritional status. The committee will include one or more administrators, surgeons, hepatologists, nurse-coordinators, social workers, pharmacists, financial/insurance specialists, and registered dietitians (RDs). The committee will also utilize all workup consultations (e.g., input from cardiologists, pulmonologists, psychiatrists, etc.). Being nutritionally compromised, which is often the case in patients with ESLD, is not a contraindication to LT, but extremes are considered in terms of surgical risk.

In the period between listing and surgery, the nutritional status of the potential recipient tends to deteriorate unless intervention occurs. Since the early years of LT, this challenge has intensified as “severity of illness before transplantation” has worsened due to larger organ demand and a limited donor pool, resulting in a longer wait list time.1–3

While Model for End-Stage Liver Disease (MELD and MELD-NA) scores do not have a direct nutritional component, the corresponding deterioration in medical condition that increases the MELD scores (worsening renal function, hyperbilirubinemia, and coagulopathy) have relationships and implications for worsening organ function and, hence, nutritional status.

Poor nutritional status can worsen the underlying liver disease and its symptoms and can negatively affect many other treatment outcomes, including patient and graft survival after transplantation.4,5

For obese patients with any type of liver disease, but especially nonalcoholic fatty liver disease (NAFLD), weight loss remains beneficial. Some patients will be candidates for bariatric therapies, but the timing and appropriateness of bariatric surgery are not clear and should be considered on a case-by-case basis.7 While helping obese patients with liver disease with weight loss, it is imperative to provide adequate protein and micronutrients.4,7,8

At the time of surgery and the immediate postoperative LT period, the patient’s nutrient needs are often higher due to surgical stress, fasting periods, and interventions and complications, all of which lead to protein catabolism.2,5

Increased needs in the immediate postoperative LT period are magnified in the setting of uncorrected, preoperative malnutrition. In both pre and post-LT phases, many patients will have difficulty meeting their nutritional needs without the aid of oral nutritional supplements or nutrition support.2,5,8,9

Recovery after surgery and a working graft will ameliorate many nutritional deficits, but within 6 months after surgery, the patient will be faced with different nutrition-related challenges, including excessive or inappropriate weight gain, hyperglycemia, dyslipidemia, hypertension (HTN), renal dysfunction, new-onset or worsening osteoporosis, and vulnerability to foodborne illness and other infections due to immune suppression.2,5

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