In a 180-patient randomised controlled trial of decompensated cirrhosis with sarcopenia, six months of dietitian-supervised intensive nutritional therapy (targeting 35–40 kcal/kg/day, 1.2–1.5 g protein/kg/day) produced a skeletal muscle index gain 2.50 cm²/m² greater than physician-delivered guideline advice, alongside handgrip strength gains of 7.5 kg (men) and 4.8 kg (women), gait velocity improvement of 0.23 m/s, and a 1.3-point drop in Child-Turcotte-Pugh score. A multidomain response occurred in 68.9% versus 37.8% of participants — a number needed to treat of just 3.2.
Sarcopenia affects 40–70% of patients with decompensated cirrhosis and is one of the strongest independent predictors of transplant waitlist mortality, yet translating nutritional guidelines into practice has long suffered from the gap between what physicians recommend and what patients actually consume. This trial makes that implementation gap quantifiable. The effect sizes are clinically meaningful — a 7.5 kg handgrip improvement exceeds the minimal clinically important difference established in general populations, and CTP improvement signals genuine hepatic reserve recovery, not just cosmetic muscle gain. Critically, the intervention is low-tech and immediately scalable: structured dietitian access rather than novel drugs or devices. Limitations include single-centre design in India (limiting generalisability), open-label allocation, and a six-month horizon insufficient to detect mortality differences. Nonetheless, for clinicians managing liver disease, this is a compelling, practice-ready signal that structured allied-health nutritional care outperforms verbal dietary advice by a wide margin.