Malnutrition and sarcopenia are highly prevalent and robustly associated with reduced quality of life, disease progression, and poor outcomes, including complications and mortality, in patients with cirrhosis. Their pathophysiology is multifactorial, involving inadequate dietary intake and malabsorption, impaired liver functional reserves, altered energy, protein, and ammonia metabolism, systemic inflammation, hormonal dysregulation, and lifestyle or environmental influences. Despite extensive research, unresolved issues remain regarding optimal diagnostic criteria, as current approaches vary and lack global standardization. Regarding the diagnostic criteria for malnutrition, the usefulness of the Global Leadership Initiative on Malnutrition criteria has been proposed by international nutrition societies. However, evidence supporting their applicability in hepatology remains insufficient. For sarcopenia, differences in disease concept and diagnostic methods among societies indicate that no unified diagnostic standard exists, and clinicians should approach diagnosis with an understanding of the strengths and limitations of each method. Nutritional strategies emphasize adequate energy and protein intake, late evening snacks, and branched-chain amino acid supplementation, while deficiencies in micronutrients require tailored replacement. Nutritional therapy alone has limited effect on sarcopenia, but when combined with exercise it improves muscle mass, physical performance, and outcomes. Comprehensive approaches integrating optimized nutrition, micronutrient support, and structured exercise are essential to alleviate the burden of malnutrition and sarcopenia and to improve prognosis in patients with cirrhosis. This review addresses malnutrition and sarcopenia in cirrhosis by highlighting their prevalence, pathophysiology, clinical impact, and approaches for screening and diagnosis, and by emphasizing personalized nutritional, pharmacological, and exercise interventions to improve patient outcomes.
Citations
Citations to this article as recorded by
Letter: Amino Acid Imbalance Is an Independent Factor for Mortality in Patients With Liver Cirrhosis. Authors' reply Yuki Utakata, Takao Miwa, Shinji Unome, Naoya Masuda, Mikita Oi, Masashi Aiba, Kenji Imai, Koji Takai, Makoto Shiraki, Naoki Katsumura, Masahito Shimizu Alimentary Pharmacology & Therapeutics.2026; 63(9): 1329. CrossRef
Covert hepatic encephalopathy as a multi-organ syndrome: the gut–liver–muscle–brain axis, diagnosis, treatment, and multidisciplinary care Takao Miwa, Cynthia L. Hsu, Masahito Shimizu, Patricia P. Bloom, Bernd Schnabl Journal of Gastroenterology.2026; 61(9): 1217. CrossRef
Nutrition in cirrhosis: bridging guidelines and practice in hepatic disease Jennifer Jin, Puneeta Tandon, Leah Gramlich Current Opinion in Clinical Nutrition & Metabolic Care.2026; 29(5): 494. CrossRef
Letter: Major Adverse Outcomes in Steatotic Liver Disease Subtypes—From Etiological Classification to Biological Phenotyping: Authors' Reply Takao Miwa, Bernd Schnabl Alimentary Pharmacology & Therapeutics.2026; 64(8): 1171. CrossRef
A 12-week home-based exercise program with nutritional guidance is associated with improved functional capacity in chronic liver disease Shinji Unome, Takao Miwa, Yoshihiko Atago, Satomi Nakashima, Kayoko Nishimura, Shinya Hiraoka, Masashi Aiba, Kenji Imai, Yohei Shirakami, Koji Takai, Takaaki Aoki, Masahito Shimizu Clinical Nutrition ESPEN.2026; 75: 105073. CrossRef
Exercise as a Metabolic Therapy for MASLD: Beyond Weight Loss Toward Sustainable Exercise Strategies Hee-Tae Roh, Ju-Yong Bae Medicina.2026; 62(4): 784. CrossRef
The impact of resistance training in patients diagnosed with metabolic dysfunction-associated steatotic liver disease: a systematic review Daniele Gorski Medeiros, Luis Fernando Ferreira, Jessica da Silva Lamp, Luis Henrique Telles da Rosa European Journal of Gastroenterology & Hepatology.2025; 37(2): 129. CrossRef
Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Although previous studies have demonstrated that exercise independently reduces hepatic steatosis measured by imaging modalities in NAFLD, the effect of exercise on histological endpoints remains unclear. We aimed to conduct a systematic review of the independent effect of exercise on hepatic steatosis, steatohepatitis, and liver fibrosis as measured by histological assessment or non-invasive tests (NITs) in biopsy-proven NAFLD. A systematic literature search of PubMed, Embase, and Web of Science databases was performed using keywords related to exercise, NAFLD, and biopsy. Articles were selected based on the following inclusion criteria: (1) involved human subjects with biopsy-proven NAFLD, (2) analyzed the independent effect of exercise, (3) assessed changes in hepatic steatosis, steatohepatitis, or liver fibrosis via either histological evaluation or NITs, and (4) were original research studies. We identified a total of six studies that analyzed the independent effect of exercise on histological endpoints in biopsy-proven NAFLD. Two randomized controlled trials (RCTs) did not detect significant histological improvement following exercise interventions, while other non-randomized interventional studies showed that exercise reduces hepatocyte ballooning and liver fibrosis. In addition, five studies assessed NIT outcomes, collectively demonstrating that exercise improves hepatic steatosis measured by magnetic resonance imaging-based techniques but not serum biomarkers for steatohepatitis and liver fibrosis. Additional large RCTs and meta-analyses are warranted to investigate the independent effect of exercise on histological and clinical outcome endpoints in NAFLD.
Citations
Citations to this article as recorded by
Physical Activity Improves Overall Survival in Patients with Hepatocellular Carcinoma Byeong Geun Song, Myeongcheol Lee, Juhee Cho, Geum-Youn Gwak, Danbee Kang, Dong Hyun Sinn Liver Cancer.2026; : 1. CrossRef
Differential Exercise Requirements for Nonalcoholic Fatty Liver Disease Resolution Across Age Groups: A Longitudinal Study of Korean Military Officers Jaejun Lee, Dong Yeup Lee, Jae Hyeop Jung, Eunkyoung Bae, Jeong A. Yu, Hyun Yang Journal of Physical Activity and Health.2025; 22(3): 323. CrossRef
Acetyl-CoA Carboxylase Inhibitors for Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Nurina Hasanatuludhhiyah, Arifa Mustika, Viskasari P. Kalanjati, Muhammad Miftahussurur, Naoto Uemura Pharmaceuticals.2025; 18(9): 1276. CrossRef
NAFLD Fibrosis Progression and Type 2 Diabetes: The Hepatic–Metabolic Interplay Simona Cernea Life.2024; 14(2): 272. CrossRef
The independent effect of exercise on biopsy proven non-alcoholic fatty liver disease: A systematic review Young-Joo Jin Clinical and Molecular Hepatology.2023; 29(2): 414. CrossRef
Diet and non-alcoholic fatty liver disease, a short narrative review W.J. Kwanten Acta Gastro Enterologica Belgica.2023; 86(2): 306. CrossRef
Higher oxidative balance scores are associated with lower nonalcoholic fatty liver disease and not with fibrosis in US adults Xuna Liu, Yiwen Wang, Xuyan Liu, Beibei Zeng, Boxu Zhu, Yue Zhang, Yan Zhuang, Yanqi Zhang, Fei Dai Nutrition, Metabolism and Cardiovascular Diseases.2023; 33(12): 2488. CrossRef
Non-Alcoholic Fatty Liver Disease, Atherosclerosis, and Cardiovascular Disease in Asia Yohwan Lim, Seogsong Jeong, Myunghee Hong, Hyun Wook Han Reviews in Cardiovascular Medicine.2023;[Epub] CrossRef
First
Prev
