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Oral nutritional interventions associated with reduced clinical events in adults with cirrhosisCan better nutrition help people with advanced liver disease?

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Key Takeaway
Consider oral nutritional support for cirrhosis patients, but note evidence shows association, not causation, for reduced clinical events.

This systematic review and meta-analysis examined the impact of various oral nutritional interventions—including branched-chain amino acids, high-protein/high-calorie diets, β-hydroxy β-methylbutyrate, and high-protein diets—in 3,128 adults with cirrhosis. The analysis included studies with follow-up of at least 4 weeks, though specific comparator details and primary outcomes were not reported.

For clinical outcomes, nutritional interventions were associated with reduced risks: overt hepatic encephalopathy (RR 0.70, 95% CI 0.52-0.95, NNT 11), liver-related decompensation events (RR 0.69, 95% CI 0.53-0.90, NNT 16), hospitalization (RR 0.65, 95% CI 0.49-0.86, NNT 8), and mortality (RR 0.64, 95% CI 0.49-0.84, NNT 23). For functional measures, handgrip strength improved by a mean difference of 2.41 kg (95% CI 0.58-4.24), and the Liver Frailty Index showed borderline improvement (MD -0.35, 95% CI -0.70 to -0.0005).

Safety and tolerability data were not reported. Key limitations include high heterogeneity that limits firm conclusions about improvements in sarcopenia and frailty, and comparator bias that prevents definitive conclusions about the relative effectiveness of different nutritional strategies. The authors note that longer-duration studies did not show significant mortality reduction, though duration was not a significant moderator in their analysis.

The findings support current guideline recommendations for nutritional support in cirrhosis. However, clinicians should interpret these as associations rather than proven causal effects, and recognize that the evidence does not establish which specific nutritional strategy is optimal for individual patients.

When your liver is scarred from cirrhosis, staying strong and avoiding hospital trips is a daily battle. A new analysis of past studies suggests that what you eat could be a powerful part of that fight. The review, which looked at data from over 3,100 adults, found that oral nutritional support—like high-protein diets or specific supplements—was linked to a lower risk of serious problems. People who got this support were less likely to be hospitalized, experience liver-related complications, or die. They also showed small improvements in handgrip strength, a sign of muscle health.

This is encouraging news that backs up what many doctors already recommend. However, the researchers point out that the evidence has some important wrinkles. The studies varied quite a bit in their methods, which makes it hard to draw firm conclusions about how much these diets improve frailty and muscle loss. It's also unclear if one type of nutritional plan is better than another.

While the analysis showed a link to a lower risk of death, studies that followed people for longer periods didn't always see this benefit. This means we can't yet say for sure that these nutritional strategies provide a long-term survival advantage. The review didn't report on side effects or how well people tolerated the different diets, which are key details for daily life.

In short, this research reinforces that good nutrition matters deeply for liver health, but more work is needed to figure out the ideal approach for each person.

What this means for you:
Better nutrition is linked to fewer hospital visits for people with cirrhosis.

Study Details

Study typeMeta analysis
EvidenceLevel 1
Follow-up0.9 mo
PublishedApr 2026
View Original Abstract ↓
BACKGROUND: Liver cirrhosis is a chronic, and progressive condition often complicated by malnutrition, sarcopenia, hepatic encephalopathy (HE), and frailty. Malnutrition is highly prevalent in patients with cirrhosis and is associated with an increased risk of decompensation and mortality. Consequently, leading liver societies (ESPEN, EASL, AASLD) recommend personalized nutritional interventions in patients with cirrhosis. While several studies have examined the effects of BCAAs on clinical and functional outcomes in cirrhosis, few have synthesized these outcomes in a single meta-analysis. Despite a growing number of RCTs on HPHC diets and HMB, existing reviews remain largely limited to sarcopenia-related outcomes. To date, no meta-analysis has evaluated the impact of nutritional interventions on frailty-related outcomes in cirrhosis. AIMS: To assess the impact of oral nutritional interventions, including branched-chain amino acids (BCAAs), high-protein, high-calorie (HPHC) diets, β-hydroxy β-methylbutyrate (HMB), and high-protein diets on clinical and functional outcomes in adults with cirrhosis. METHODS: We conducted a systematic review and meta-analysis of 21 randomized controlled trials (RCTs), of which 18 involving 3128 adults with cirrhosis were included in the meta-analysis, following PRISMA 2020 guidelines. RCTs published between January 1, 2000, and June 1, 2025, involving ≥4 weeks of oral nutritional therapy in patients with cirrhosis were included. Data were pooled using random effects model. Sensitivity, subgroup, and meta-regression analyses explored robustness and potential effect modifiers. The certainty of evidence was assessed using GRADE criteria. RESULTS: Nutritional intervention significantly reduced the risk of overt HE (RR 0.70; 95 % CI 0.52-0.95; NNT 11; I 0 %), liver-related decompensation events (RR 0.69; 95 % CI 0.53-0.90; NNT 16; I 0 %), hospitalization (RR 0.65; 95 % CI 0.49-0.86; NNT 8; I 21.8 %), and mortality (RR 0.64; 95 % CI 0.49-0.84; NNT 23; I 0 %). Handgrip strength improved significantly (MD 2.41 kg; 95 % CI 0.58-4.24; I 87 %), and LFI showed borderline improvement (MD -0.35; 95 % CI -0.70 to -0.0005; I 84.4 %). HPHC diets appeared more effective than BCAAs for mortality and HGS, though comparator bias limits definitive conclusions. Meta-regression indicated greater mortality benefit with higher MELD scores. While studies ≤6 months showed significant mortality reduction, longer-duration studies did not; however, duration was not a significant moderator in subgroup analysis or meta-regression. CONCLUSION: Oral nutritional therapy is associated with reduced risk of decompensation, overt hepatic encephalopathy, hospitalization, and short-term mortality in cirrhosis. While improvements in sarcopenia and frailty were observed, high heterogeneity limits firm conclusions. These findings support current guidelines and highlight the need for longer-duration and head-to-head trials to identify optimal nutritional strategies. PROSPERO REGISTRATION: CRD420251073182.
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