Nutritional issues in patients with obesity and cirrhosis

Table 1 Impact of obesity on liver pathophysiology

Pathologies	Obesity
Hepatic steatosis[9]	Increased1
Cirrhosis[11]	Increased1
Hepatoxicity[9]	Increased1
Liver primary tumors (as hepatocarcinoma)[2-4]	Increased2
Chronic hepatitis C progression[12]	Increased
Decompensation of cirrhotic patients[13,14]	Increased
Portal hypertension[13,14]	Increased
3Risk of post-operative complications after LT[15-17]	Increased

¹Mostly if associated to alcohol ingestion;

²Mostly if associated to non-alcoholic fatty liver disease (NAFLD);

³Thromboembolism, infectious and biliary complications. LT: Liver transplantation.

Table 2 Nutritional recommendations for cirrhotic patients with obesity

Nutrient	Recommendation
1Daily energy intake[117]	25-35 kcal/(kg•d) in patients with BMI 30-40 kg/m2 20-25 kcal/(kg•d) in patients with BMI > 40 kg/m2
2Protein intake[119]	1.2-1.5 g/(kg•d)
3Micronutrients	Identify and correct micronutrient deficiencies
Fiber	25-45 g/d

¹The recommended dietary pattern is for small, frequent meals evenly distributed throughout the day (every 3-6 h) with a late evening snack containing at least 50 g of complex carbohydrate.

²Vegetable-protein based diets can also be beneficial in terms of caloric and fiber intake among overweight patients with cirrhosis who are attempting to lose weight. In addition, plant-based proteins are rich in branched-chain amino acids (BCAA)[117,127,128].

³Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and should be supplemented appropriately. BMI: Body mass index.

Table 3 Main factors involved in the choice of the bariatric procedure in the setting of liver transplantation

Factors to consider	SG	RYGB
Bleeding risk of bleeding1	Increased	Low
Endoscopic access to the biliary tree	Conserved	Impossible
Risk of portal vein thrombosis	Increased	Not affected
Risk of bariatric surgery induced liver failure	Absent	Low
Absorption of immunosuppressive drugs	Poorly affected	Decreased
Etiology of liver cirrhosis (NASH vs others)	Effective	Very Effective

¹Consider measuring of portal pressure and use of transjugular intrahepatic portosystemic shunt in case of bariatric surgery before liver transplantation. SG: Sleeve gastrectomy; RYGP: Roux-en-Y gastric bypass; NASH: Non-alcoholic steato hepatitis.