for Health Care Providers
Nutrition in Advanced Liver Disease - Cirrhosis
Healthy diet choices are the same in advanced liver disease (ALD) as for early liver disease: View the early liver disease section. When liver disease progresses, lack of appetite, nausea and vomiting can influence eating and result in malnutrition. Poor absorption and increased losses of nutrients also contribute to malnutrition. Protein is not restricted even with ALD but you should not consume protein in large amounts. The liver does not store energy well so eating smaller, more frequent meals (4-5 times per day) may be better tolerated.
ALD causes the kidneys to hold sodium (salt) which then results in your body holding more fluid thus increasing ascites (swollen abdomen) and swelling of the hands, legs and feet. Your provider may ask that you restrict your sodium intake to 2000 mg or less (1 teaspoon of salt contains approximately 2300mg sodium). Sodium in all foods and beverages must be calculated into this amount. Reading sodium content on packaging will be necessary. You should remember that the sodium content on the package is for the serving size indicated on the label, not for the entire amount of the package. If you have chronic kidney disease, salt substitutes should be avoided because they are high in potassium.
Your provider will tell you if or when you need to restrict your fluid intake. If fluid is restricted it usually is 1500-2000 ml per day. A good way to track your fluid intake for a day is to fill a pitcher with the amount of water as your daily restriction. Every time you drink a beverage discard the same amount of fluid from the pitcher. Individuals are often prescribed diuretics (water pills) at this stage of liver disease so you may feel thirsty. If you are on a fluid restriction, there are tricks to relieve the thirsty feeling. Sugar-free frozen pops, sugar-free sour candy, sugar-free gelatin, sucking on lemon or lime slices and eating ice cold fruit and vegetables will help relieve thirst. Frozen grapes are a good option. Fluid from the sugar-free frozen pops and gelatin must be included in the daily allowance of fluid intake, as will the fluid in juicy fruit like watermelon. Refer to the BEVERAGE section in the early liver disease section for more guidance.
Nutrition supplements are recommended at the discretion of your provider. If your appetite will allow, a snack before bedtime is beneficial to maintain proper metabolism.
Vitamins and Minerals
As in early liver disease, Vitamin B1 and vitamin B2, which are included in most multivitamins, may be taken. Vitamin A may be taken, however, there is a fine line between not enough and too much. An excess amount of vitamin A can injure your already sick liver. Vitamin C supplement may be taken unless you have hemochromatosis. If you have jaundice (yellow skin and eyes), you may not only be low in fat soluble vitamins A and E but also vitamins D and K and may need special replacement.
Fatigue, muscle weakness and twitches and cramps of your arms, hands and feet may indicate magnesium deficiency in ALD. Your provider may order a blood test to determine magnesium level and, if low, a supplement will be ordered. ALD may also cause a zinc deficiency. Signs of a zinc deficiency include decreased appetite, decreased ability to fight infection, diarrhea and hair loss. A zinc supplement may be ordered by your provider. Muscle cramps can also be relieved with drinking either regular or diet tonic water because of the quinine content. It is important not to drink more than 4 ounces per day because of the high sodium content.
If you have Wilson's Disease, foods high in copper need to be eliminated from the diet. These foods include organ meats, shellfish, chocolate, nuts, mushrooms, kale, asparagus, parsley, potatoes with skin (both white and sweet), lima beans, soybean sprouts and spinach.
If you have Hemochromatosis, iron supplements, multivitamins with iron and Vitamin C supplements should be avoided.