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Usefulness of nutritional therapy recommended in the Japanese Society of Gastroenterology/Japan Society of Hepatology evidence-based clinical practice guidelines for liver cirrhosis 2020



The JSGE/JSH guidelines for the management of patients with liver cirrhosis revised in 2020 recommends new strategies for nutritional assessment and intervention, although their usefulness in daily clinical practice is unclear.


A total of 769 patients with cirrhosis were classified into low-, intermediate-, and high-risk groups according to hypoalbuminemia and sarcopenia, the criteria established for initiating the nutritional therapy algorithm in the guidelines. The association between these groups and mortality was analyzed using a Cox proportional hazards model. The effect of branched-chain amino acids (BCAAs) on survival was evaluated using propensity score matching.


Of the enrolled patients, 495 (64%) were men with a median age of 73 years, 428 (56%) had hypoalbuminemia, 156 (20%) had sarcopenia, and 288 (37%) were receiving BCAAs. During a median follow-up period of 1.5 years, 276 (36%) patients died. The intermediate-risk [hazard ratio (HR), 1.60; 95% confidence interval (CI), 1.18–2.18] and high-risk (HR, 2.85; 95% CI, 1.92–4.23) groups independently predicted mortality. Among the propensity score-matched 250 patients, 49 (39%) BCAA-treated and 58 (46%) untreated died. Overall survival was higher in BCAA-treated patients than in untreated patients (HR, 0.67; 95% CI, 0.46–0.98). The survival benefit of BCAAs was pronounced in the intermediate-risk (HR, 0.50; 95% CI, 0.31–0.80) and high-risk (HR, 0.38; 95% CI, 0.16–0.91) groups.


The 2020 JSGE/JSH guidelines for liver cirrhosis are useful in stratifying the mortality risk and providing effective nutritional interventions for malnourished patients with cirrhosis.

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All authors contributed to the conception and design of this study. Data collection and analysis were performed by Tatsunori Hanai, Kayoko Nishimura, Takao Miwa, Toshihide Maeda, Yui Ogiso, Kenji Imai, Atsushi Suetsugu, and Koji Takai. The first draft of the manuscript was written by Tatsunori Hanai, and all authors commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.

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Correspondence to Tatsunori Hanai.

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Hanai, T., Nishimura, K., Miwa, T. et al. Usefulness of nutritional therapy recommended in the Japanese Society of Gastroenterology/Japan Society of Hepatology evidence-based clinical practice guidelines for liver cirrhosis 2020. J Gastroenterol 56, 928–937 (2021).

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  • Branched-chain amino acids
  • Cirrhosis
  • Malnutrition
  • Nutritional intervention
  • Sarcopenia