Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice

Lai, Jennifer C.; Sonnenday, Christopher J.; Tapper, Elliot B.; Duarte‐Rojo, Andrés; Dunn, Michael A.; Bernal, William; Carey, Elizabeth J.; Dasarathy, Srinivasan; Kamath, Binita M.; Kappus, Matthew R.; Montaño-Loza, Aldo J.; Nagai, Shunji; Tandon, Puneeta

doi:10.1111/ajt.15392

Cited by 201 publications

(278 citation statements)

References 30 publications

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“…This area warrants further investigation. Muscle tests need to be tailored to age‐appropriate levels of function with consideration to clinical conditions, time, psychometric properties, and resources (interdisciplinary team expertise) required to implement muscle function tests in inpatient and outpatient settings …”

Section: Discussionmentioning

confidence: 99%

Pediatric Sarcopenia: A Paradigm in the Overall Definition of Malnutrition in Children?

Ooi

Thompson‐Hodgetts

Pritchard

et al. 2019

J Parenter Enteral Nutr

119

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Background Malnutrition is a common complication in children with chronic diseases. Sarcopenia is one component of malnutrition, characterized by reduced skeletal muscle mass (SMM) and muscle function. The presence of sarcopenia is associated with adverse outcomes in children. Although there is growing research interest in sarcopenia, no review has been done on this novel concept in pediatrics. The purpose of this review was to explore current evidence in sarcopenia with and without obesity and to evaluate the knowledge gaps in the assessment of childhood sarcopenia. Methods A total of 12 articles retrieved from PubMed or Web of Science databases were included. Results Limited studies have elucidated sarcopenia in pediatrics. Challenges in sarcopenia assessment include heterogeneity in definition and absence of standardized body composition methods used to measure SMM and muscle function tests. There is a lack of age‐specific and gender‐specific normative data for SMM, particularly in young children and infants. None of the studies incorporated muscle function assessment, causing potential bias and misclassification of sarcopenia. The research in childhood sarcopenia is also hampered by low study quality, limited number of outcomes‐based research, and lack of longitudinal data. Conclusion Consensus needs to be reached in methodological approaches in sarcopenia diagnosis, body composition measurements, and age‐appropriate muscle function tests in pediatrics. Careful considerations on growth, neurocognitive status, and factors influencing development in various clinical populations are warranted. Early identification of sarcopenia is crucial to enable targeted treatment and prevention to be carried out across the pediatric clinical populations.

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Section: Discussionmentioning

confidence: 99%

Pediatric Sarcopenia: A Paradigm in the Overall Definition of Malnutrition in Children?

Ooi

Thompson‐Hodgetts

Pritchard

et al. 2019

J Parenter Enteral Nutr

119

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“…(Table and Figure ) In addition , frailty has recently emerged as a strong predictor of outcomes in patients with cirrhosis, independent of liver function, and has made its way into decision‐making within LT . Therefore, the American Society of Transplantation has recommended risk stratification for LT candidates by using standardised simple frailty assessment tools such as the Liver Frailty Index, Clinical Frailty Scale (CFS), Six‐minute walk test, Karnofsky Performance Status scale and Short Physical Performance Battery (SPPB) . Frailty tools have been best studied in the outpatient setting (or in the patients’ with steady state) …”

Section: Assessment and Diagnosis Of Malnutrition/ Sarcopenia And Framentioning

confidence: 99%

“…In the setting of LT, malnutrition, sarcopenia and frailty adversely impact outcomes in patients on the waitlist, in the peri‐LT and post‐LT period . The presence of sarcopenia is predictive of waitlist mortality in addition to MELD score .…”

Section: Consequences Of Malnutrition Sarcopenia and Frailty In Cirrhmentioning

confidence: 99%

“…The presence of sarcopenia is predictive of waitlist mortality in addition to MELD score . Furthermore, the presence of frailty is associated with waitlist mortality independent of MELD and CP scores . Of note, frailty appears to be a more useful indicator for functional capacity or quality of life in LT candidates, than the presence of sarcopenia .…”

Section: Consequences Of Malnutrition Sarcopenia and Frailty In Cirrhmentioning

confidence: 99%

“…Sarcopenia is defined by generalised reduction in muscle mass and function due to ageing (primary sarcopenia), or acute or chronic illness (secondary sarcopenia), including cirrhosis. Frailty is a multi‐dimensional construct that represents the end‐manifestation of derangements of multiple physiologic systems leading to decreased physiologic reserve and increased vulnerability to health stressors . These three conditions are increasingly common among patients with cirrhosis, particularly in those with decompensated liver disease, and in fact relatively overlap (but not identical), and all contributing to physical deconditioning and increased mortality .…”

Section: Introductionmentioning

confidence: 99%

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Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis

Bunchorntavakul

Reddy

2019

Aliment Pharmacol Ther

146

131

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Summary Background Malnutrition/sarcopenia and frailty are common in patients with cirrhosis and are associated with poor outcomes. Aim To provide an overview of data on the importance, assessment and management of malnutrition/sarcopenia and frailty in cirrhosis. Methods A literature search was conducted in PubMed and other sources, using the search terms “sarcopenia,” “muscle,” “malnutrition,” “cirrhosis,” “liver” and “frailty” from inception to April 2019, to identify the relevant studies and international guidelines. Results The prevalence of malnutrition/sarcopenia in cirrhosis is 23%‐60%. Frailty generally overlaps with malnutrition/sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition/sarcopenia in cirrhosis is complex/multifactorial and not just reduction in protein/calorie intake. Hyperammonemia appears to be the main driver of sarcopenia in cirrhosis through several molecular signalling pathways. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched‐chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality‐ and liver‐related events, they, and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long‐term ammonia‐lowering agents and myostatin antagonists, are currently under investigation. Conclusions Malnutrition/sarcopenia and frailty are unique, inter‐related and multi‐dimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.

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Association Between Liver Transplant Wait-list Mortality and Frailty Based on Body Mass Index

et al. 2019

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IMPORTANCE Among liver transplant candidates, obesity and frailty are associated with increased risk of death while they are on the wait-list. However, use of body mass index (BMI) may not detect candidates at a higher risk of death owing to the fact that ascites and muscle wasting are seen across transplant candidates of all BMI measurements. OBJECTIVE To evaluate whether the association between wait-list mortality and frailty varied by BMI of liver transplant candidates. DESIGN, SETTING, AND PARTICIPANTSA prospective cohort study was conducted at 9 liver transplant centers in the United States from March 1, 2012, to May 1, 2018, among 1108 adult liver transplant candidates without hepatocellular carcinoma.EXPOSURES At outpatient evaluation, the Liver Frailty Index score was calculated (grip strength, chair stands, and balance), with frailty defined as a Liver Frailty Index score of 4.5 or more. Candidates' BMI was categorized as nonobese (18.5-29.9), class 1 obesity (30.0-34.9), and class 2 or greater obesity (Ն35.0). MAIN OUTCOMES AND MEASURESThe risk of wait-list mortality was quantified using competing risks regression by candidate frailty, adjusting for age, sex, race/ethnicity, Model for End-stage Liver Disease Sodium score, cause of liver disease, and ascites, including an interaction with candidate BMI. RESULTSOf 1108 liver transplant candidates (474 women and 634 men; mean [SD] age, 55 [10] years), 290 (26.2%) were frail; 170 of 670 nonobese candidates (25.4%), 64 of 246 candidates with class 1 obesity (26.0%), and 56 of 192 candidates with class 2 or greater obesity (29.2%) were frail (P = .57). Frail nonobese candidates and frail candidates with class 1 obesity had a higher risk of wait-list mortality compared with their nonfrail counterparts (nonobese candidates: adjusted subhazard ratio, 1.54; 95% CI, 1.02-2.33; P = .04; and candidates with class 1 obesity: adjusted subhazard ratio, 1.72; 95% CI, 0.99-2.99; P = .06; P = .75 for interaction). However, frail candidates with class 2 or greater obesity had a 3.19-fold higher adjusted risk of wait-list mortality compared with nonfrail candidates with class 2 or greater obesity (95% CI, 1.75-5.82; P < .001; P = .047 for interaction).CONCLUSIONS AND RELEVANCE This study's finding suggest that among nonobese liver transplant candidates and candidates with class 1 obesity, frailty was associated with a 2-fold higher risk of wait-list mortality. However, the mortality risk associated with frailty differed for candidates with class 2 or greater obesity, with frail candidates having a more than 3-fold higher risk of wait-list mortality compared with nonfrail patients. Frailty assessments may help to identify vulnerable patients, particularly those with a BMI of 35.0 or more, in whom a clinician's visual evaluation may be less reliable to assess muscle mass and nutritional status.

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Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice

Abstract: Abbreviation: ADLs, activities of daily living.

Cited by 201 publications

References 30 publications

Pediatric Sarcopenia: A Paradigm in the Overall Definition of Malnutrition in Children?

Pediatric Sarcopenia: A Paradigm in the Overall Definition of Malnutrition in Children?

Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis

Association Between Liver Transplant Wait-list Mortality and Frailty Based on Body Mass Index

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