Differing Impact of Sarcopenia and Frailty in Nonalcoholic Steatohepatitis and Alcoholic Liver Disease

Abstract

Sarcopenia and frailty are commonly encountered in patients with end‐stage liver disease and are associated with adverse clinical outcomes, including decompensation and wait‐list mortality. The impact of these entities in patients with differing disease etiologies has not been elucidated. We aim to ascertain the change in their prevalence over time on the wait list and determine their impact on hospitalization, delisting, and wait‐list survival, specifically for patients with nonalcoholic steatohepatitis (NASH) and alcoholic liver disease (ALD). Adult patients who were evaluated for their first liver transplant from 2014 to 2016 with a primary diagnosis of NASH (n = 136) or ALD (n = 129) were included. Computed tomography scans were used to determine the presence of sarcopenia and myosteatosis. Frailty was diagnosed using the Rockwood frailty index. Patients with NASH had a significantly lower prevalence of sarcopenia (22% versus 47%; P < 0.001) but a significantly higher prevalence of frailty (49% versus 34%; P = 0.03) when compared with patients with ALD at the time of listing. In patients with NASH, sarcopenia was not associated with adverse events, but a higher frailty score was associated with an increased length of hospitalization (P = 0.05) and an increased risk of delisting (P = 0.02). In patients with ALD, univariate analysis showed the presence of sarcopenia was associated with an increased risk of delisting (P = 0.01). In conclusion, sarcopenia and frailty occur with differing prevalence with variable impact on outcomes in wait‐listed patients with NASH and ALD.

Functional Status and Liver Disease Phenotype: Frailty, Thy Presence Is Ominous

“…Contrary to the current study, where lower KPSS was seen in patients with ALD, two other recent studies utilizing other assessment tools have reported that the underlying liver disease most associated with frailty is in fact NASH [9,10]. One of these studies objectively assessed frailty and functional status using hand grip, timed chair stands, and balance testing.…”

“…The second study employed the Rockwood frailty index, which evaluates subjective and objective variables, showed that while frailty was more common in NASH, sarcopenia (using radiologic muscle assessment) was more common in ALD. With multivariate analysis, neither frailty nor sarcopenia among ALD patients impacted delisting [10]. These observations validate the aforementioned concerns about the limited reliability of KPSS.…”

Sarcopenia and Frailty in the Prognosis of Patients on the Liver Transplant Waiting List

“…In conclusion, the current study by Bhanji et al underscores the importance of muscularity and frailty assessment as part of LT assessment, in order to better predict outcomes in patients with cirrhosis. However, prospective longitudinal studies with a larger number of patients are required to overcome the obstacles in our current understanding of the predictive value of sarcopenia and frailty in patients with various etiologies of cirrhosis.…”

“…(5) Standardized techniques are required to diagnose and manage sarcopenia and frailty in LT patients at initial and serial assessments.Cirrhosis due to nonalcoholic steatohepatitis (NASH) and alcoholic liver disease (ALD) are now the most common indications for LT. Despite this, there has been a lack of information about the risk factors and implications in patients with a diagnosis of NASH or ALD (Table 1).In this issue of Liver Transplantation, Bhanji et al (9) address this issue by evaluating 136 patients with NASH and 129 with ALD-related cirrhosis. The prevalence of sarcopenia, as analyzed by computed tomography (CT) scan, was lower in patients with NASH (22% versus 47%; P < 0.001) but with a considerably higher frequency of frailty, which was defined using the frailty deficit index (49% versus 34%; P = 0.03) when compared with patients with ALD at the time of listing.…”

Current management of non‐alcoholic steatohepatitis

“…Patients may require a liver transplant once they develop decompensated cirrhosis, hepatocellular carcinoma (HCC) or certain other complications of cirrhosis. NASH patients with cirrhosis may also develop sarcopenia and frailty, which can worsen their waiting list mortality . After liver transplantation, these patients must take diabetogenic medications such as steroids, tacrolimus and mammalian target of rapamycin inhibitors to prevent allograft rejection because of their increased metabolic risk.…”