Sarcopenia and frailty in decompensated cirrhosis

Abstract

In patients with decompensated cirrhosis, sarcopenia and frailty are prevalent. Although several definitions exist for these terms, in the field of hepatology, sarcopenia has commonly been defined as loss of muscle mass, and frailty has been broadly defined as the phenotypic manifestation of the loss of muscle function. Prompt recognition and accurate assessment of these conditions are critical as they are both strongly associated with morbidity, mortality, poor quality of life and worse post-liver transplant outcomes in patients with cirrhosis. In this review, we describe the complex pathophysiology that underlies the clinical phenotypes of sarcopenia and frailty, their association with decompensation, and provide an overview of tools to assess these conditions in patients with cirrhosis. When available, we highlight data focusing on patients with acutely decompensated cirrhosis, such as inpatients, as this is an area of unmet clinical need. Finally, we discuss management strategies to reverse and/or prevent the development of sarcopenia and frailty, which include adequate nutritional intake of calories and protein, as well as regular exercise of at least moderate intensity, with a mix of aerobic and resistance training. Key knowledge gaps in our understanding of sarcopenia and frailty in decompensated cirrhosis remain, including best methods to measure muscle mass and function in the inpatient setting, racial/ethnic variation in the development and presentation of sarcopenia and frailty, and optimal clinical metrics to assess response to therapeutic interventions that translate into a reduction in adverse outcomes associated with these conditions.

Hospital Frailty Risk Score Is Independently Associated with Mortality and Encephalopathy in Hospitalized Patients with Hepatocellular Carcinoma

“…Factors that contribute to general frailty, including altered gut microbiota, sarcopenia and endotoxemia, are drivers of liver decompensation in HCC [ 21 ]. Several factors contribute to sarcopenia in cirrhosis including low glycogen deposits, lack of adequate energy sources, and physical inactivity [ 21 ]. Alterations in the gut microbiota can lead to systemic endotoxemia which activates Toll-like receptors on muscle.…”

“…This leads to increased protein breakdown and reduction in protein synthesis, resulting in sarcopenia. Sarcopenia, which is a key contributing factor in frailty and has been associated with a poor quality of life, mortality pre- and post-liver transplant, and longer hospital stay [ 21 ].…”

“…The frailty group included patients with larger tumor size, higher rate of postoperative complications, and longer length of stay. The study also showed worse disease-free survival rates in the frailty group [ 21 ].…”

Albumin Substitution in Decompensated Liver Cirrhosis: Don’t Forget Zinc

“…Acute decompensation is complex, and its development and progression remain unpredictable [19]. It can be precipitated by bacterial infection, liver injury, or other known and unknown mechanisms [6] and leads to the development of a range of complications, including ascites, hepatic encephalopathy (HE), hepatorenal syndrome (HRS), variceal bleeding, sarcopenia, and further bacterial infections [19][20][21]. In about a third of patients with acute decompensation, ACLF and multiple organ failure follow.…”

New concepts and perspectives in decompensated cirrhosis

“…This is followed by a chapter detailing new concepts in the pathogenesis, assessment and management of sarcopenia and frailty, which have been shown to impact heavily on patients with cirrhosis. 11 The final two chapters focus on the sickest patients with decompensated cirrhosis. The first of these is devoted to intensive care management of these patients with extremely high attendant risk of death 12 and the second to the issues surrounding liver transplantation of patients with ACLF and multiorgan failure.…”