Physical inactivity, sarcopenia, and frailty are highly prevalent, independent predictors of morbidity and mortality in patients with cirrhosis. Across a range of chronic diseases, exercise training is a key recommendation supported by guidelines and, for some conditions, even by governmental funding of exercise programmes. Consistent with the broader chronic disease literature, the evidence for a benefit of exercise in cirrhosis is promising. Several small trials have reported significant improvements in muscle health (mass, strength, functional capacity), quality of life, fatigue, and reductions in the hepatic venous pressure gradient, without adverse events. With strong emerging evidence surrounding the substantial risks of sarcopenia/frailty and our first-hand experiences with liver pre-transplant exercise programmes, we contend that routine patient care in cirrhosis should include an exercise prescription. Some clinicians may lack the resources and necessary background to translate the existing evidence into a practicable intervention. Our team, comprised of physiotherapists, exercise physiologists, hepatologists, transplant specialists, and knowledge translation experts from six North American centres, has distilled the essential background information, tools, and practices into a set of information ready for immediate implementation into clinics ranging from a family practice setting to specialty cirrhosis clinics. Augmenting the rationale and evidence are supplementary materials including video and downloadable materials for both patients and the physician. Supporting the exercising patient is a section regarding information about nutrition, providing practical tips suitable for all patients with cirrhosis.

Frailty is an important predictor of increased hospitalization risk, length of stay, and mortality in patients with cirrhosis. The American Society of Transplantation guidance statement supports the 6-minute walk test distance (6MWD) as 1 of 4 tools to be included in a cirrhosis frailty toolkit. (1) Although routinely used to support prognostication in patients with cardiopulmonary diseases and to select patients for heart and lung transplantation, (2) evidence for the use of the 6MWD with cirrhosis is evolving. The most commonly used cutoff to predict mortality in cirrhosis (<250 m) is derived from data by Carey et al. (3) in 121 patients listed for liver transplantation (LT) and later confirmed by Yadav et al. (4) in 213 transplantlisted patients. Building on existing work, the aim of this study was to evaluate the predictive value of the 6MWD in a larger sample of patients with cirrhosis who were being evaluated for LT.

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