Safety and Efficacy of Ketogenic Diet for Promoting Weight Loss in Obese Individuals With Compensated NASH Cirrhosis

This is an open-label, randomized study comparing a monitored ketogenic diet intervention using standard ketogenic diet (SKD) and standard of care (SOC) dietary recommendations for 16 weeks. Subjects enrolled in the standard of care group will receive a voucher to Weight Watchers after study completion.

The primary aim is to assess the safety of ketogenic diet as compared to standard of care approach for weight loss in patients with compensated cirrhosis due to NASH. The safety endpoints captured in the study include liver decompensation events, measured through several questionnaires, fasting blood glucose, serum creatinine, fasting lipid profile and other adverse events. The tolerability of the ketogenic diet will be assessed by study compliance and by administering a questionnaire. Secondary aims include weight loss, changes in body composition via serial use of bioelectrical impedance via an Inbody Machine, changes in liver fat and liver stiffness using MRI and proton density fat fraction (MRI-PDFF), liver biochemistries, changes in Child-Turcotte-Pugh and MELD scores measured via labs and changes in liver steatosis and stiffness via serial measures of VCTE by FibroScan®.

Inclusion Criteria: 1. NASH cirrhosis (criteria in Appendix 1) with obesity (BMI \>30 kg/m2). 2. Age 18 and greater Exclusion Criteria: 1. Actively participation in investigational drug treatment for non-alcoholic fatty liver disease 2. Currently taking medications for weight loss or have joined a supervised weight loss program prior to enrollment 3. Have hepatocellular carcinoma and are undergoing therapy 4. Women who become pregnant or plan to become pregnant prior to the study date; female subjects who become pregnant during the study will be withdrawn from the study 5. Pacemaker or implantable cardioverter devices 6. History of hepatic surgery 7. Current significant alcohol consumption, defined as more than 20 grams per day in females or 30 grams per day in males 8. Presence of ascites or hepatic encephalopathy 9. Symptomatic gastroparesis 10. Uncontrolled diabetes, as defined by a HgbA1C \>11% 11. Uncontrolled congestive heart failure 12. Active infections 13. Child Turcotte Pugh score \> 6 14. MELD score \>12 15. Unwilling to undergo an MRI or have contraindications to an MRI