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Patients with chronic liver disease are often malnourished. Clinical assessment of nutritional status is difficult in this patient population because of the confounding effects of abnormalities of hydration status and protein metaboHsm. To overcome these difficulties, a global method of assessment incorporating objective and subjective data was developed. Its reproducibility and internal validity were confirmed and it was used to assess the prevalence of malnutrition in 215 patients with cirrhosis. The relationship between global nutritional status and outcome was examined in 271 liver transplant candidates. Pre-transplant malnutrition was significantly associated with a reduced survival 90 days after surgery. Many factors contribute to impaired nutritional status in patients with cirrhosis. The potential effects of hypermetabolism were examined by measuring resting energy expenditure in 100 patients with cirrhosis and a group of comparable healthy volunteers. Resting energy expenditure was significantly higher in the patients when adjusted for fluid retention and fat-free mass, determined using anthropometry. Further nutrition research in patients with chronic liver disease is hampered by an absence of validated methods of accurately assessing body composition. Such data are required, not only to fully vahdate clinical assessment techniques, but also to quantify metabolically active tissue and fat compartments which are essential prerequisites in energy expenditure, protein turnover and nutrition intervention studies. The difficulties of assessing body composition in chronic liver disease may be overcome by using a four-compartment model in which total body water, mineral, fat and protein are assessed. This model was applied to 20 patients with cirrhosis who underwent underwater weighing, deuterium dilution and dual-energy X-ray absorptiometry studies. The results were compared with bedside methods of assessments and significant differences found. The hydration fraction of fat-free mass varied between 71.7–83.0%. Although this model of body composition assessment is a research tool, it has shown the limitations of other techniques and provided data upon which further studies can be based.