Introduction: Nutrition assessment remains difficult in children with chronic liver disease. Indirect calorimetry (IC) is a test to directly measure resting energy expenditure (REE). This study aims to assess the feasibility of IC in pre-liver transplant patients and report nutrition outcomes.  

Methods: We identified all pre-transplant patients who underwent IC at our institution from 1/2020 to 11/2025. Demographics, anthropometrics, estimated REE (eREE), nutrition recommendations pre- and post-IC, validity of IC, measured REE (mREE) and transplant outcomes were collected.  eREE was calculated using Schofield equation. Hypermetabolism was defined as mREE >110% eREE. 

Results: 15 pre-transplant patients underwent IC at median age of 16 months (range 5-205). IC was valid in 67% patients (10/15). Invalid IC was due to inability to reach steady state in 5/5 patients. Of patients with valid studies, 70% were hypermetabolic. 50% of patients had an increase in recommended calories based on mREE. Of those who had post-transplant mortality (3/15), 2/3 were hypermetabolic and 1/3 had an invalid study.  

Discussion: Malnutrition is known to contribute to poor transplant outcomes. Nutrition assessment in chronic liver disease is difficult due to ascites, malabsorption, and fluid status. In our study, IC identified hypermetabolism in 70% of patients and led to an increase in caloric provision in 50%. Limitations include feasibility of NPO prior to IC, as well as difficulty achieving steady state for a valid test, especially in young infants. IC is a useful tool to measure REE and can help guide nutrition recommendations in children awaiting liver transplant.