Nutritional management in deceased donor liver transplantation: A case study of decompensated chronic liver disease with hepatocellular carcinoma
Malarkodi M1*, Rithika Shree S², Hemalatha B3, Sruthi G4
Department of Clinical Nutrition and Dietetics, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu
*Correspondence
Abstract
Liver transplantation (LT) represents the definitive treatment for end-stage liver disease, but perioperative nutritional management remains a critical determinant of post-operative outcomes. Malnutrition is nearly universal in patients with decompensated chronic liver disease (DCLD) and is independently associated with increased morbidity, prolonged hospital stay, and reduced graft survival. This case report describes the comprehensive nutritional management of a 67-year-old male patient with DCLD, portal hypertension, hepatocellular carcinoma (HCC), and a Model for End-Stage Liver Disease (MELD) score of 20, who underwent a successful deceased donor liver transplant (DDLT) at Kauvery Hospital, Radial Road. The case highlights a three-phase nutritional intervention, pre-transplant workup, peri-operative/post-transplant, and outpatient follow-up incorporating tailored energy and protein targets, enteral nutrition progression, management of chyle leak with a fat-free medium-chain triglyceride (MCT) diet, and immunosuppression-aligned food safety protocols. At follow-up, the patient achieved 98% of caloric targets and 99% of protein targets, with remarkable improvements in serum albumin (2.46 to 3.86 g/dL), total bilirubin (4.89 to 0.36 mg/dL), and SGOT (421 to 17 U/L), underscoring the vital role of the clinical nutrition team in the multidisciplinary transplant programme.
Keywords: Liver transplantation; Nutritional management; Decompensated chronic liver disease; Hepatocellular carcinoma; MELD score; Chyle leak; MCT diet; Albumin; Enteral nutrition; Multidisciplinary team
Introduction
Chronic liver disease (CLD) and its end-stage sequelae impose a profound burden on nutritional status. Protein-energy malnutrition occurs in 65–100% of patients awaiting liver transplantation and correlates directly with post-operative complications, graft dysfunction, and mortality. In India, the etiology of CLD encompasses alcohol-related liver disease, non-alcoholic steatohepatitis, viral hepatitis, and increasingly, hepatocellular carcinoma arising from cirrhotic backgrounds.
Deceased donor liver transplantation (DDLT) offers a life-saving option, but the physiological demands of major hepatic surgery combined with pre-existing sarcopenia, ascites, encephalopathy, and immunosuppression create a uniquely challenging nutritional environment. Registered dietitians embedded within the transplant multidisciplinary team (MDT) are pivotal in optimising patient’s nutritional status prior to transplant and sustaining adequate intake through the acute post-operative and ambulatory recovery phases.
We present a case from the Liver Transplant Programme of Kauvery Hospital, Radial Road, Chennai, documenting the clinical course and nutritional interventions across all three phases of care for a 67-year-old male with DCLD, portal hypertension, and HCC who underwent DDLT with a MELD score of 20.
Case Presentation
Patient Profile and Pre-Transplant Workup
A 67-year-old male was admitted to Kauvery Hospital, Radial Road on 06 February 2026 for pre-transplant evaluation and management. The admitting diagnosis was decompensated chronic liver disease with hepatic encephalopathy Grade III, ascites, pedal edema, and portal hypertension. The patient’s presenting complaint was acute altered sensorium of one day’s duration, accompanied by repetition of words, abnormal behaviour, and disorientation. He denied fever, vomiting, chest pain, or dyspnoea.
His past medical history was notable for Type 2 diabetes mellitus, hypertension, and recurrent decompensation of CLD. Four days prior to admission, he had undergone large volume paracentesis (LVP) of 4 litres. He had a history of large fundal varices managed with glue injection in January 2026, and recurrent ascites requiring periodic LVP. The underlying etiology was alcohol-related liver disease with concomitant HCC. His MELD score was calculated at 20, indicating advanced disease and transplant necessity.
The pre-workup admission lasted six days (06–12 February 2026), during which pre-transplant workup was completed, hepatic encephalopathy managed, and nutritional assessment initiated.
Nutritional Assessment
A detailed anthropometric and nutritional assessment was performed on admission and compared with measurements from the pre-workup clinic visit (Table 1). The patient had a dry weight of 66.7 kg (actual weight 83.4 kg with ascites) and a height of 172 cm, yielding a BMI of 22.6 kg/m² on a dry weight basis. Mid-upper arm circumference (MUAC) was 24 cm and triceps skinfold thickness 12 mm. Handgrip strength measured 14.1 kg (left hand). Subjective Global Assessment (SGA) scored 22, consistent with moderate malnutrition.
At admission for transplant (16 February 2026), MUAC declined to 22 cm and skinfold to 11 mm, while weight was 67 kg. SGA remained 22, indicating persistent moderate malnutrition despite the intervening pre-workup period.
Table 1: Anthropometric Parameters Longitudinal Comparison across All Three Phases
| Parameter | Pre-Workup | Transplant Admission | Follow-Up |
|---|---|---|---|
| Height (cm) | 172 | 172 | 172 |
| Weight (kg) | 66.7 (dry) | 67.0 | 61.3 |
| BMI (kg/m²) | 22.6 | 22.87 | 20.7 |
| IBW (kg) | 72 | 72 | 72 |
| MUAC (cm) | 24 | 22 | 21 |
| Skinfold (mm) | 12 | 11 | 10 |
| Handgrip (kg) | 14.1 (L) | 14.5 (L) | 14.7 (L) |
| SGA Score | 22 | 22 | 12 — |
| Mod. Malnourished | Mod. Malnourished | Well Nourished |
Biochemical Parameters
On admission during pre-workup, haemoglobin was 8.9 g/dL, serum albumin 2.54 g/dL, total bilirubin 4.05 mg/dL, and serum urea 53 mg/dL. Liver enzymes were within acceptable ranges for the degree of cirrhosis (SGOT 29 U/L, SGPT 20 U/L). Creatinine was 1.0 mg/dL, sodium 136 mEq/L, and potassium 4.4 mEq/L. By discharge (12 February 2026), haemoglobin had fallen to 7.2 g/dL and urea normalised to 43 mg/dL (Table 2).
On admission for transplantation (16 February 2026), the expected post-operative rise in transaminases was observed SGOT peaked at 421 U/L and SGPT at 215 U/L, reflecting ischemia-reperfusion injury. Total bilirubin was 4.89 mg/dL. By discharge on 24 February 2026, SGOT had declined to 50 U/L and bilirubin to 1.32 mg/dL, indicating early graft function. Serum albumin improved marginally from 2.46 to 2.89 g/dL. Urea rose to 138 mg/dL at discharge, likely reflecting increased protein catabolism and high protein supplementation, with creatinine of 1.2 mg/dL (Table 3).
Table 2: Biochemical Parameters Pre-Workup Phase (06–12 February 2026)
| Parameter | On Admission | On Discharge |
|---|---|---|
| Haemoglobin (g/dL) | 8.9 | 7.2 |
| Urea (mg/dL) | 53 | 43 |
| Creatinine (mg/dL) | 1.0 | 0.7 |
| Sodium (mEq/L) | 136 | 136 |
| Potassium (mEq/L) | 4.4 | 3.9 |
| Total Bilirubin (mg/dL) | 4.05 | — |
| SGOT (U/L) | 29 | — |
| SGPT (U/L) | 20 | — |
| Alkaline Phosphatase (U/L) | 57 | — |
| Total Protein (g/dL) | 6.06 | — |
| Albumin (g/dL) | 2.54 | — |
Table 3: Biochemical Parameters Post-Transplant Phase (16–24 February 2026)
| Parameter | On Admission | On Discharge |
|---|---|---|
| Haemoglobin (g/dL) | 9.7 | 6.0 |
| Urea (mg/dL) | 69 | 138 |
| Creatinine (mg/dL) | 0.8 | 1.2 |
| Sodium (mEq/L) | 138 | 130 |
| Potassium (mEq/L) | 4.4 | 5.1 |
| Total Bilirubin (mg/dL) | 4.89 | 1.32 |
| SGOT (U/L) | 421 | 50 |
| SGPT (U/L) | 215 | 124 |
| Alkaline Phosphatase (U/L) | 29 | 137 |
| Total Protein (g/dL) | 4.79 | 4.94 |
| Albumin (g/dL) | 2.46 | 2.89 |
Table 4: Longitudinal Biochemical Comparison across all Phases
| Parameter | Pre-Workup (Discharge) | Post-Transplant (Discharge) | Follow-Up |
|---|---|---|---|
| Haemoglobin (g/dL) | 7.2 | 6.0 | 11.1 |
| Urea (mg/dL) | 43 | 138 | 32.7 |
| Creatinine (mg/dL) | 0.7 | 1.2 | 0.56 |
| Sodium (mEq/L) | 136 | 130 | 141 |
| Potassium (mEq/L) | 3.9 | 5.1 | 4.39 |
| Total Bilirubin (mg/dL) | 4.05 | 1.32 | 0.36 |
| SGOT (U/L) | 29 | 50 | 15 |
| SGPT (U/L) | 20 | 124 | 24 |
| Alkaline Phosphatase (U/L) | 57 | 137 | 78 |
| Total Protein (g/dL) | 6.06 | 4.94 | 6.19 |
| Albumin (g/dL) | 2.54 | 2.89 | 3.86 |
Nutritional Management
Phase I: Pre-Transplant Workup (06–12 February 2026)
Energy requirement was estimated at 1,800 kcal/day (approximately 27 kcal/kg dry body weight), and protein target was set at 80 g/day (approximately 1.2 g/kg dry body weight), in line with EASL and ESPEN guidelines for pre-transplant management. A sodium-restricted (4 g/day), fluid-restricted (1.5 L/day), low-fat, diabetic-friendly diet was prescribed. Branched-chain amino acid (BCAA)-enriched oral nutritional supplements (ONS) were incorporated to support protein synthesis while mitigating the risk of exacerbating encephalopathy through aromatic amino acid load.
Daily dietary intake was monitored by the dietetics team and communicated in real-time to the Nutrition Support Team. On discharge (12 February 2026), the patient was advised to continue the above regimen with BCAA-based ONS and regular outpatient follow-up in preparation for transplant.
Phase II: Peri-operative and Post-Transplant Phase (16–24 February 2026)
The patient was admitted for transplant on 16 February 2026 and underwent DDLT the same day. Post-operative energy requirements were escalated to 2,000 kcal/day and protein targets to 100 g/day, consistent with ESPEN guidelines for post-operative major hepatic surgery.
Enteral nutrition (EN) was commenced early post-operatively via nasogastric tube and progressively transitioned to oral feeding over the ICU and ward stay. A critical complication post-transplant chyle leak necessitated initiation of a fat-free, MCT-based modified diet, which was carefully maintained while sustaining protein-energy delivery targets. Fluid and electrolyte management was prioritised throughout the peri-operative period given the risk of hyponatraemia and hyperkalaemia observed on discharge (sodium 130 mEq/L, potassium 5.1 mEq/L).
Gastrointestinal intolerance manifesting as bloating and nausea, likely related to immunosuppressive medications was managed through dietetic counselling, small frequent feeds, and oral top-up supplementation. The patient remained on three days of ICU monitoring followed by a five-day ward stay before discharge on 24 February 2026.
Phase III: Outpatient Follow-Up
At follow-up, energy requirements were further escalated to 2,200 kcal/day and protein to 110 g/day to support ongoing tissue repair, muscle mass reconstitution, and adaptation to immunosuppressive therapy. The patient achieved 98% of caloric targets and 99% of protein targets at this phase a testament to sustained patient cooperation, dietetic engagement, and continuation of oral top-up supplementation after discharge.
Discharge prescriptions at both hospital admissions and follow-up are summarised in Table 5.
Table 5: Nutritional Prescription across all Three Phases
| Parameter | Pre-Workup Discharge | Post-Transplant Discharge | Follow-Up |
|---|---|---|---|
| Energy (kcal/day) | 1,800 | 2,000 | 2,200 |
| Protein (g/day) | ~80 (High Protein) | 100 | 110 |
| Fat Type | Low Fat | MCT-based Diet | MCT-based Diet |
| Carbohydrate | Diabetic Diet | Diabetic Diet | Diabetic Diet |
| Sodium | 4 g/day limit | As tolerated | As tolerated |
| Fluid | 1.5 L/day limit | As clinically guided | As clinically guided |
| Food Safety | Standard | Neutropenic Diet | Neutropenic Diet |
| ONS | BCAA-based ONS | MCT oil + BCAA ONS | MCT oil + BCAA ONS |
Post-Transplant Food Safety and Immunosuppression Considerations
Immunosuppressive therapy following transplantation places recipients at significant risk of opportunistic infection. Neutropenic dietary precautions were instituted at discharge and maintained through the outpatient phase. Recommended practices included:
- Thorough cooking of all foods; serve freshly prepared and hot
- Avoiding leftovers; consuming food within manufacturer use-by dates
- Use of individually sealed, single-serve food packets where possible
- Rigorous hand hygiene with soap and hot water prior to all food handling
- Consumption of only thick-skinned fruits, thoroughly washed with peel removed
- Use of separate cutting boards for poultry and seafood
- Drinking only boiled, cooled water
Foods and practices explicitly contraindicated included: opened food packets, raw or half-boiled eggs, hard or blue or cream cheese, shellfish, dry fruits, unpackaged sauces, raw salads or raita, fresh fruits from outside, street food, and reheated meals. These precautions align with standard neutropenic diet protocols and guidelines from transplant societies.
Clinical Nutrition Challenges
Several nutritional challenges were identified and managed across the clinical course:
Poor Oral Intake: Post-operative nausea, fatigue, and the side-effect profile of immunosuppressive medications significantly reduced the patient’s appetite and voluntary intake. This was addressed through small frequent meals, calorie-dense ONS, and close dietetic monitoring.
Protein-Energy Balance: Escalating requirements from pre-transplant to post-operative recovery required stepwise upward titration of targets while monitoring gastrointestinal tolerance and renal function (urea peaked at 138 mg/dL post-discharge).
Fluid and Electrolyte Management: Peri-transplant fluid restriction for ascites management had to be carefully balanced against adequate nutrient delivery. Post-operative hyponatraemia (sodium 130 mEq/L) and borderline hyperkalaemia (potassium 5.1 mEq/L) required close monitoring and dietary modification.
Gastrointestinal Intolerance: Bloating and nausea in the post-operative phase delayed advancement from EN to oral diet. This was managed by incremental feed progression and adjusting the timing and composition of oral intake.
Chyle Leak: Post-transplant chyle leak represented a clinically significant complication requiring immediate transition to a fat-free, MCT-modified diet. MCT fats are absorbed directly via the portal circulation, bypassing the lymphatic system and thus reducing chylous drainage, while still providing a calorie-dense fat source. Protein and energy targets were maintained throughout this modification.
Dietary Compliance: Adherence to transplant dietary restrictions particularly neutropenic food safety precautions and sodium restriction was reinforced through structured patient and family education. The strong engagement of the patient’s family was identified as a key enabler of dietary adherence.
Outcomes
The patient was discharged in stable condition on 24 February 2026 following an eight-day post-transplant admission (three days ICU, five days ward). At outpatient follow-up, remarkable clinical and nutritional improvements were documented:
- Serum albumin improved from 2.46 g/dL (post-transplant admission) to 3.86 g/dL at follow-up approaching normal reference range
- Total bilirubin normalised from 4.89 mg/dL to 0.36 mg/dL, indicating excellent graft function
- SGOT declined from a peak of 421 U/L to 15 U/L, confirming hepatocellular recovery
- Haemoglobin recovered to 11.1 g/dL from 6.0 g/dL at post-transplant discharge
- Creatinine normalised to 0.56 mg/dL and urea to 32.7 mg/dL, indicating renal recovery
- SGA score improved from 22 (moderately malnourished) to 12 (well nourished)
- Caloric target achievement: 98% (2,156 of 2,200 kcal/day)
- Protein target achievement: 99% (109 of 110 g/day)
The follow-up visit confirmed continued MCT oil and BCAA-based ONS supplementation, compliance with neutropenic dietary precautions, and regular outpatient attendance. MUAC was 21 cm and handgrip strength 14.7 kg, reflecting early-phase muscle reconstitution.
Discussion
This case illustrates the multifaceted nutritional challenges inherent in managing a patient with DCLD, portal hypertension, HCC, hepatic encephalopathy, and a MELD score of 20 through deceased donor liver transplantation. The progressive three-phase nutritional strategy beginning with pre-transplant optimisation, transitioning through the acute post-operative period, and sustaining gains through outpatient follow-up achieved clinically meaningful improvements in biochemical, anthropometric, and functional parameters.
Sarcopenia and malnutrition in pre-transplant CLD are well-recognised independent predictors of post-operative morbidity and mortality. In this patient, baseline MUAC and skinfold measurements confirmed marginal muscle and fat stores despite a preserved BMI — a pattern of sarcopenic obesity that is common in patients with ascites-related weight overestimation. SGA scoring, which accounts for functional and dietary history alongside physical assessment, appropriately captured the degree of nutritional compromise.
The management of post-transplant chyle leak with a fat-free, MCT-based diet exemplifies the need for specialised nutritional knowledge within the transplant MDT. Chyle leak is a recognised complication following DDLT, occurring in approximately 1–3% of cases, and requires prompt dietary intervention to reduce lymphatic flow and facilitate resolution. In the present case, this was successfully managed without recourse to parenteral nutrition, highlighting the feasibility of meeting nutritional targets via modified oral and enteral feeding even in the presence of this complication.
The achievement of 98–99% of energy and protein targets at follow-up reflects both the efficacy of the dietetics team’s intervention and the critical role of patient and family engagement. Structured nutritional counselling, proactive monitoring, and continuation of ONS supplementation post-discharge were instrumental in this achievement. The rise in serum albumin from 2.46 to 3.86 g/dL a well-validated marker of nutritional rehabilitation and hepatic synthetic function provides objective evidence of the success of this integrated approach.
The role of the multidisciplinary team cannot be overstated. Daily communication between the clinical dietetics team and the broader Nutrition Support Team encompassing hepatologists, transplant surgeons, pharmacists, and nursing enabled real-time dietary adjustments responsive to evolving clinical status. This integrated model of care aligns with best practice frameworks endorsed by ESPEN, EASL, and the British Dietetic Association for liver transplantation.
Conclusion
This case demonstrates that a structured, phase-specific nutritional intervention, delivered by a specialist dietetics team within an integrated multidisciplinary transplant programme, can achieve clinically significant nutritional rehabilitation in a patient with advanced decompensated chronic liver disease undergoing deceased donor liver transplantation. Key lessons include:
- Early and comprehensive nutritional screening using validated tools (SGA, anthropometry, handgrip) is essential in pre-transplant assessment
- Phase-specific energy and protein targets should be titrated upward across the transplant journey to match evolving metabolic demands
- Complications such as chyle leak require specialised nutritional adaptation; fat-free MCT-modified diets can successfully sustain nutritional targets while facilitating resolution
- Post-transplant neutropenic dietary precautions are a critical component of infection prevention under immunosuppression
- Patient and family education, and active engagement in dietary adherence, are independent enablers of successful nutritional outcomes
- Daily monitoring and MDT communication enable real-time optimisation of nutritional care
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