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Editorial: diastolic dysfunction seems not to be decisive for survival after transjugular intrahepatic portosystemic stent-shunt

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Despite several studies showing increased mus-
cle mass, quality of life and exercise capacity after short intensive
physical activity programmes, there is no existing evidence suggest-
ing that these interventions alter waitlist or posttransplant out-
Given the strong associations found in the literature with
poor patient outcomes as well as the concerning signals noted in the
study by Bhanji et al, a controlled, prospective study is warranted to
track outcomes and body composition changes, and test the efficacy
of interventions for this important problem.
The writing and preparation of this paper were funded in part by NIH
grant T32DK077662 PI MM Abecassis. Drs. Mazumder and Rinella
wrote the paper. Dr. Rinella designed and created the figure. Dr.
Rinella takes responsibility for the integrity of the work as a whole,
from inception to published article. All authors approved the final ver-
sion of the manuscript. Dr. Mazumder was funded in part by NIH
grant T32DK077662 PI MM Abecassis. Dr. Rinella provides consult-
ing services to the following companies and organizations: Intercept,
Gilead, Genfit, Enanta, BMS, Novartis, NGM Bio, Immuron, Cymabay,
Merck, Viking, Gelesis, Allergan, Metacrine, Thetis, Fractyl and
Chronic Liver Disease Foundation (CLDF). She is on scientific advisory
boards for the following companies: Intercept, Gilead, Enanta, Novar-
tis and NGM Bio. She has received independent research funding
from Novartis. She is on no Speakers Bureaus and owns no stock in
companies with which she has any involvement. She serves as an
Associate Editor for Hepatology and Seminars in Liver Disease.
Nikhilesh Mazumder
This article is linked to Bhanji et al paper. To view this article, visit
Nikhilesh Mazumder
Mary Rinella
Division of Hepatology, Department of Medicine Feinberg School of
Medicine, Northwestern University, Chicago, Illinois
1. van Vugt JLA, Levolger S, de Bruin RWF, van Rosmalen J, Metselaar
HJ, IJzermans JNM. Systematic review and metaanalysis of the
impact of computed tomographyassessed skeletal muscle mass on
outcome in patients awaiting or undergoing liver transplantation. Am
J Transplant. 2016;16:22772292.
2. Bhanji RA, Takahashi N, Moynagh MR, et al. The evolution and
impact of sarcopenia preand postliver transplantation. Aliment
Pharmacol Ther. 2019;49:807813.
3. Krell RW, Kaul DR, Martin AR, et al. Association between sarcopenia
and the risk of serious infection among adults undergoing liver trans-
plantation. Liver Transpl. 2013;19:13961402.
4. MontanoLoza AJ. Clinical relevance of sarcopenia in patients with
cirrhosis. World J Gastroenterol. 2014;20:80618071.
5. Dasarathy S, McCullough AJ, Muc S, et al. Sarcopenia associated
with portosystemic shunting is reversed by follistatin. J Hepatol.
6. Semsarian C, Wu MJ, Ju YK, et al. Skeletal muscle hypertrophy is
mediated by a Ca2+dependent calcineurin signalling pathway. Nat-
ure. 1999;400:576581.
7. Wang CW, Feng S, Covinsky KE, et al. A comparison of muscle func-
tion, mass, and quality in liver transplant candidates: results from the
functional assessment in liver transplantation study. Transplantation.
8. Sinclair M, Grossmann M, Hoermann R, Angus PW, Gow PJ. Testos-
terone therapy increases muscle mass in men with cirrhosis and low
testosterone: a randomised controlled trial. J Hepatol. 2016;65:906
9. Tsien C, Shah SN, McCullough AJ, Dasarathy S. Reversal of sarcope-
nia predicts survival after a transjugular intrahepatic portosystemic
stent. Eur J Gastroenterol Hepatol. 2013;25:8593.
10. Kaido T, Ogawa K, Fujimoto Y, et al. Impact of sarcopenia on sur-
vival in patients undergoing living donor liver transplantation. Am J
Transplant. 2013;13:15491556.
11. Kruger C, McNeely ML, Bailey RJ, et al. Home exercise training
improves exercise capacity in cirrhosis patients: role of exercise
adherence. Sci Rep. 2018;8:99.
DOI: 10.1111/apt.15221
Editorial: diastolic dysfunction seems not to be decisive for
survival after transjugular intrahepatic portosystemic stentshunt
Armstrong et al take a closer look at cardiac diagnostics in patients eval-
uated for transjugular intrahepatic portosystemic stentshunt (TIPSS)
Although highly selected in their patients, presence of dias-
tolic dysfunction was not associated with survival, but Model for End
Stage Liver Disease (MELD) score remained the best predictor of
survival. The clinical gutfeelingand pathophysiological understanding
suggest that the cardiac function should play a role and should be inves-
tigated prior to TIPSS insertion in these patients.
Therefore, the ques-
tion arises, is echocardiography relevant for selection of patients to
TIPSS and if yes what parameters are the relevant ones?
©2019 John Wiley & Sons Ltd
... Armstrong et al. examined a large cohort of 117 patients but none of the echocardiography measures pre-intervention were related to 30-day or overall transplant-free survival after TIPS insertion. Hence, there are no reliable parameters in echocardiography to predict outcome and overall survival in these patients (11,12). In the present study, we found no correlation between TTE parameters before and after TIPS insertion with survival. ...
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Background Left ventricular global longitudinal strain (LV-GLS) has been shown to better reflect the left cardiac contractility in cirrhosis than other investigations and might bear prognostic value. The aim of this study was to investigate the evolution of myocardial contractility assessed by speckle tracking echocardiography (STE) after transjugular intrahepatic portosystemic shunt (TIPS) placement and its prognostic value in outcome. Methods In this study, 206 (126 males) patients with liver cirrhosis receiving TIPS were included. In all study patients, conventional transthoracic echocardiography (TTE) was performed before and in the first weeks after TIPS placement to assess left and right ventricular volume, planar and functional parameters. Also, LV-GLS was measured by STE to assess left ventricular contractility as surrogate for myocardial dysfunction. Hemodynamic and clinical parameters were assessed before TIPS and during follow-up. Results As expected, most conventional parameters of TTE showed a significant change after TIPS placement. However, neither the absolute values, nor the changes of conventional cardiac parameters of TTE before and after TIPS insertion were associated with survival. By contrast, an increase in contractility of more than 20% using STE after TIPS was an independent predictor of mortality. Conclusion These results demonstrate that an increase of left ventricular contractility of more than 20% after TIPS insertion is an independent predictor of survival and this may identify patients at risk and in need of closer follow-up care.
Background and aims: Left ventricular diastolic dysfunction (LVDD) in cirrhotics are associated with circulatory dysfunction, hepatorenal syndrome (HRS) and heart failure in stressful conditions. Transjugular intrahepatic portosystemic shunt (TIPS) exacerbates the hyperdynamic circulation and challenges cardiac function. We evaluated the incidence and the impact of LVDD in cirrhotic candidates to TIPS for refractory ascites. Methods: Among 135 patients who underwent TIPS for refractory ascites, 63 cases (child B/C 53/10, Na-model for end-stage liver disease 16.5 ± 0.9) who had 2D-transthoracic-echocardiography with tissue-Doppler-imaging pre-TIPS were retrospectively analysed (group A); in 23 cases cardiac and hormonal assessment before and after TIPS was available. 41 cirrhotics without refractory ascites treated by banding ligation for variceal re-bleeding were used as controls (group B). Results: The prevalence of LVDD was higher in group A (59%; 22% with grade ≥2) as compared to group B (35%; 7% with grade ≥2) (P < 0.01 and P < 0.03). A lack of clinical response to TIPS occurred in 10 patients, all with LVDD (P < 0.03 vs. no LVDD) and in patients with grade ≥2 LVDD mostly (P < 0.02 vs. grade 1). Central venous pressure >20 mmHg after TIPS and left ventricular end-diastolic volume at basal were predictors of no response to TIPS (P = 0.01 and P = 0.004, respectively), which was an independent predictor of death. Elevated levels of NT-proBNP 3 days after TIPS were associated with advanced cardiac dysfunction (P = 0.005). Conclusion: NT-proBNP and careful LVDD investigation are useful to better select patients and to predict clinical response and mortality after TIPS.
Objectives: Transjugular intrahepatic portosystemic shunt (TIPS) insertion is an established treatment to lower portal pressure. There are no obligatory evidence-based recommendations addressing procedure and anticoagulation. Therefore, a survey was performed to establish current practice at different German hospitals. Methods: A three-page survey was sent out via postal mail to 76 different hospitals addressing the topics indication, contraindication, follow-up and anticoagulation. Results: Forty-three hospitals completed the survey: the median number of TIPS/year was 28.6 ± 23. Ascites and hydrothorax were announced as the main indications. Bilirubin levels above 5 mg/dl, hepatic encephalopathy and cardiac disease were considered as absolute contraindications in most hospitals, but age was not. The biggest variations were reported with regard to anticoagulation after TIPS procedure. Four hospitals never used any anticoagulation; most hospitals reported the use of low molecular weight heparins for a period of days up to 4 weeks. But also aspirin or clopidogrel was used after TIPS insertion in eight different hospitals. Additionally, the standards for follow-up after TIPS insertion were different in the hospitals. Conclusions: There is no consensus how to handle indication, contraindications and anticoagulation after the TIPS procedure. A national and international consensus is warranted to improve the outcome of TIPS patients and reduce secondary complications. In addition to compare results and efficacy in the future standard operation procedures as proposed here need to be put in place.
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Background Cardiac dysfunction is frequently observed in patients with cirrhosis. There remains a paucity of data from routine clinical practice regarding the role of echocardiography in the pre‐assessment of transjugular intrahepatic portosystemic stent‐shunt. Aim Our study aimed to investigate if echocardiography parameters predict outcomes after transjugular intrahepatic portosystemic stent‐shunt insertion in cirrhosis. Methods Patients who underwent echocardiography and transjugular intrahepatic portosystemic stent‐shunt insertion at the liver unit (Birmingham, UK) between 1999 and 2016 were included. All echocardiography measures (including left ventricle ejection fraction; early maximal ventricular filling/late filling velocity ratio, diastolic dysfunction as per British Society of Echocardiography guidelines) were independently reviewed by a cardiologist. Predictors of 30‐day and overall transplant free‐survival were assessed. Results One Hundred and Seventeen patients with cirrhosis (median age 56 years; 54% alcohol; Child‐Pugh B/C 71/14.5%; Model For End‐Stage Liver Disease 12) underwent transjugular intrahepatic portosystemic stent‐shunt for ascites (n = 78) and variceal haemorrhage (n = 39). Thirty‐day and overall transplant‐free survival was 90% (n = 105) and 31% (n = 36), respectively, over a median 663 (IQR 385‐2368) days follow‐up. Model for End‐Stage Liver Disease (P < 0.001) and Child‐Pugh Score (P = 0.002) significantly predicted 30‐day and overall transplant‐free survival. Model for End‐Stage Liver Disease ≥15 implied three‐fold risk of death. Six per cent (n = 7) of patients pre‐transjugular intrahepatic portosystemic stent‐shunt had a history of ischaemic heart disease and 34% (n = 40) had 1 or more cardiovascular disease risk factors. Fifty per cent (n = 59) had an abnormal echocardiogram and 33% (n = 39) had grade 1‐3 diastolic dysfunction. On univariate analysis none of the echocardiography measures pre‐intervention were related to 30‐day or overall transplant‐free survival post‐transjugular intrahepatic portosystemic stent‐shunt. Conclusions Ventricular, in particular diastolic dysfunction in patients with cirrhosis does not predict survival after transjugular intrahepatic portosystemic stent‐shunt insertion. Model for End‐Stage Liver Disease and Child‐Pugh scores remain the best predictors of survival. Further prospective study is required to clarify the role of routine echocardiography prior to transjugular intrahepatic portosystemic stent‐shunt insertion.
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Background Sarcopenia is associated with both increased wait‐list mortality and mortality following liver transplantation. Aims To determine the course of sarcopenia from transplant evaluation until 1 year post‐transplant, and its implications on hospitalisation and mortality following liver transplantation. Methods Two hundred and ninety‐three transplant recipients from 2002 to 2006 had pre‐transplant CT scans analysed at the third lumbar region for sarcopenia, myosteatosis and abdominal visceral fat content. Half the recipients had post‐transplant CT scan for interpretation (161/293). Results Sarcopenia was present in 146/293 (50%) of the patients pre‐transplant. There was a significant decrease in muscle mass (loss 2.0 ± 4.9 cm²/m²; P < 0.001), and an increase in myosteatosis while awaiting liver transplantation. There was no significant change in abdominal visceral fat. For every 1 cm²/m² decrease in muscle mass there was an increase in post‐transplant length of stay by 0.36 days (P = 0.005). Post‐transplant, 98/161 (61%) of patients with CT imaging had sarcopenia (25 de novo and 73 persistent), with continued increase in myosteatosis, lower Hounsfield units (−5.0 [IQR −8.6 to 0.1]; P < 0.001) and an increase in abdominal visceral fat (4.9 [IQR −4.4 to 15.6] cm²/m²; P < 0.001). There was no statistically significant difference in 1‐year mortality in patients with de novo sarcopenia compared to patients with sarcopenia both pre‐ and post‐transplant (HR 1.88; P = 0.088). Conclusions Sarcopenia progresses up to 1 year following liver transplantation and is associated with an increase in post‐transplant length of stay.
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Acute deterioration of liver cirrhosis (e.g., infections, acute‐on‐chronic liver failure [ACLF]) requires an increase in cardiac contractility. The insufficiency to respond to these situations could be deleterious. Left ventricular global longitudinal strain (LV‐GLS) has been shown to reflect left cardiac contractility in cirrhosis better than other parameters and might bear prognostic value. Therefore, this retrospective study investigated the role of LV‐GLS in the outcome after transjugular intrahepatic portosystemic shunt (TIPS) and the development of ACLF. We included 114 patients (48 female patients) from the Noninvasive Evaluation Program for TIPS and Their Follow‐Up Network (NEPTUN) cohort. This number provided sufficient quality and structured follow‐up with the possibility of calculating major scores (Child, Model for End‐Stage Liver Disease [MELD], Chronic Liver Failure Consortium acute decompensation [CLIF‐C AD] scores) and recording of the events (development of decompensation episode and ACLF). We analyzed the association of LV‐GLS with overall mortality and development of ACLF in patients with TIPS. LV‐GLS was independently associated with overall mortality (hazard ratio [HR], 1.123; 95% confidence interval [CI],1.010‐1.250) together with aspartate aminotransferase (HR, 1.009; 95% CI, 1.004‐1.014) and CLIF‐C AD score (HR, 1.080; 95% CI, 1.018‐1.137). Area under the receiver operating characteristic curve (AUROC) analysis for LV‐GLS for overall survival showed higher area under the curve (AUC) than MELD and CLIF‐C AD scores (AUC, 0.688 versus 0.646 and 0.573, respectively). The best AUROC‐determined LV‐GLS cutoff was −16.6% to identify patients with a significantly worse outcome after TIPS at 3 months, 6 months, and overall. LV‐GLS was independently associated with development of ACLF (HR, 1.613; 95% CI, 1.025‐2.540) together with a MELD score above 15 (HR, 2.222; 95% CI, 1.400‐3.528). Conclusion: LV‐GLS is useful for identifying patients at risk of developing ACLF and a worse outcome after TIPS. Although validation is required, this tool might help to stratify risk in patients receiving TIPS. Increase in cardiac contractility is required in physical stress situations due to acute deterioration of liver disease (e.g. acute‐on‐chronic liver failure (ACLF)) or interventions (e.g. transjugular intrahepatic portosystemic shunt (TIPS)). The insufficiency to respond to these situations might be deleterious. This study demonstrated the usefulness of LV‐GLS to identify patients at risk of developing ACLF and worse outcome after TIPS.
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Cirrhosis patients have reduced peak aerobic power (peak VO2) that is associated with reduced survival. Supervised exercise training increases exercise tolerance. The effect of home-based exercise training (HET) in cirrhosis is unknown. The objective was to evaluate the safety and efficacy of 8 weeks of HET on peak VO2, 6-minute walk distance (6MWD), muscle mass, and quality of life in cirrhosis. Random assignment to 8 weeks of HET (moderate to high intensity cycling exercise, 3 days/week) or usual care. Exercise adherence defined as completing ≥80% training sessions. Paired t-tests and analysis of covariance used for comparisons. Forty patients enrolled: 58% male, mean age 57 y, 70% Child Pugh-A. Between group increases in peak VO2 (1.7, 95% CI: -0.33 to 3.7 ml/kg/min, p = 0.09) and 6MWD (33.7, 95% CI: 5.1 to 62.4 m, p = 0.02) were greater after HET versus usual care. Improvements even more marked in adherent subjects for peak VO2 (2.8, 95% CI: 0.5-5.2 mL/kg/min, p = 0.02) and 6MWD (46.4, 95% CI: 12.4-80.5 m, p = 0.009). No adverse events occurred during testing or HET. Eight weeks of HET is a safe and effective intervention to improve exercise capacity in cirrhosis, with maximal benefits occurring in those who complete ≥80% of the program.
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Background: Sarcopenia and functional impairment are common and lethal extrahepatic manifestations of cirrhosis. We aimed to determine the association between computed tomography (CT)-based measures of muscle mass and quality (sarcopenia) and performance-based measures of muscle function. Methods: Adults listed for liver transplant underwent testing of muscle function (grip strength, Short Physical Performance Battery [SPPB]) within 3 months of abdominal CT. Muscle mass (cm/m) = total cross-sectional area of psoas, paraspinal, and abdominal wall muscles at L3 on CT, normalized for height. Muscle quality = mean Hounsfield units for total skeletal muscle area at L3. Results: Among 292 candidates, median grip strength was 31 kg, SPPB score was 11, muscle mass was 49 cm/m, and muscle quality was 35 Hounsfield units. Grip strength weakly correlated with muscle mass (ρ = 0.26, P < 0.001) and quality (ρ = 0.27, P < 0.001) in men, and muscle quality (ρ = 0.23, P = 0.02), but not muscle mass, in women. Short Physical Performance Battery correlated weakly with muscle quality in men (ρ = 0.38, P < 0.001) and women (ρ = 0.25, P = 0.02), however, did not correlate with muscle mass in men or women. After adjustment for sex, model for end-stage liver disease (MELD)-Na, hepatocellular carcinoma, and body mass index, grip strength (hazard ratio [HR], 0.74; 95% confidence interval [95% CI], 0.59-0.92; P = 0.008), SPPB (HR, 0.89; 95% CI, 0.82-0.97; P = 0.01), and muscle quality (HR, 0.77; 95% CI, 0.63-0.95; P = 0.02) were associated with waitlist mortality, but muscle mass was not (HR, 0.91; 95% CI, 0.75-1.11; P = 0.35). Conclusions: Performance-based tests of muscle function are only modestly associated with CT-based muscle measures. Given that they predict waitlist mortality and can be conducted quickly and economically, tests of muscle function may have greater clinical utility than CT-based measures of sarcopenia.
The natural history of cirrhosis is characterised by an asymptomatic compensated phase followed by a decompensated phase, marked by the development of overt clinical signs, the most frequent of which are ascites, bleeding, encephalopathy, and jaundice. The following Clinical Practice Guidelines (CPGs) represent the first CPGs on the management of decompensated cirrhosis. In this context, the panel of experts, having emphasised the importance of initiating aetiologic treatment for any degree of hepatic disease at the earliest possible stage, extended its work to all the complications of cirrhosis, which had not been covered by the European Association for the Study of the Liver guidelines, namely: ascites, refractory ascites, hyponatremia, gastrointestinal bleeding, bacterial infections, acute kidney injury, hepatorenal syndrome, acute-on-chronic liver failure, relative adrenal failure, cirrhotic cardiomyopathy, hepatopulmonary syndrome, and porto-pulmonary hypertension. The panel of experts, produced these GPGs using evidence from PubMed and Cochrane database searches providing up to date guidance on the management of decompensated cirrhosis with the only purpose of improving clinical practice.
Does transjugular intrahepatic portosystemic shunt stent (TIPS) improve survival in a subgroup of patients? Yes. TIPS nearly halves portal pressure and increases the effective blood volume. In cases of acute variceal hemorrhage and with a high risk of treatment failure, defined as either hepatic venous pressure gradient higher than 20 mm Hg, Child B with active bleeding at the endoscopy, or Child C with less than 14 points, early or preemptive placement of TIPS (within 72 hours) improves survival. Also, in suitable patients with intractable or refractory ascites, TIPS improves survival if placed early in the course of treatment. While TIPS does not improve survival in other situations, it improves disease management, especially in patients without TIPS contraindications but with refractory bleeding, early rebleeding, portal vein thrombosis, and hepatorenal syndrome. Experience gained at the centers and follow-up of TIPS patients are key features that improve outcome. Important factors for selection and follow-up include cardiac function, inflammation, sarcopenia, age, and early evaluation for liver transplantation.
Background: Late allocation of organs for transplant impairs post liver transplant (LT) survival. Cardiac dysfunction, especially diastolic and autonomic dysfunction, is frequent and plays an important role in the prognosis of cirrhotic patients. However, the role of myocardial contractility is unexplored and its prognostic value is controversially discussed. This study analyses the role of myocardial contractility assessed by speckle tracking echocardiography in LT allocation. Methods: 168 cirrhotic patients (training cohort: 111, validation cohort: 57) awaiting LT in two centers were included in this retrospective study. Results: 51 patients from the training and all patients from the validation cohort were transplanted; 36 patients of the training and 38 of the validation cohort were alive at the end of follow-up; 21 non-transplanted patients died. Contractility of the left ventricle increased with severity of the Child-Pugh score. Interestingly, higher left ventricular contractility in the training cohort patients, especially in those with Child-Pugh C, was an independent predictor of reduced transplant-free survival. In male patients, the effects on survival of increased left and right ventricular myocardial contractility were more pronounced. Of note, competing risk analysis demonstrated that increased contractility is associated with earlier LT, which could be confirmed in the validation cohort. Importantly, left ventricular myocardial contractility had no impact on survival of patients not receiving LT or on post LT survival. Conclusion: This study demonstrates for the first time that increased myocardial contractility in decompensated patients identifies patients who require LT earlier, but without increased post LT mortality. This article is protected by copyright. All rights reserved.
Low testosterone and sarcopenia are common in men with cirrhosis and both are associated with increased mortality. Whether testosterone therapy in cirrhosis improves muscle mass and other outcomes is unknown. We conducted a 12 month, double-blinded, placebo-controlled trial of intramuscular testosterone undecanoate in 101 men with established cirrhosis and low serum testosterone (total testosterone <12nmol/L or free testosterone <230pmol/L) in a single tertiary centre. Body composition was assessed using dual-energy X-ray absorptiometry at baseline, 6 and 12 months. At study completion, appendicular lean mass was significant higher in testosterone-treated subjects, with a mean adjusted difference (MAD) of +1.69kg, (CI +0.40; +2.97kg, p=0.021). Secondary outcomes included a substantially higher total lean mass in the active group (MAD +4.74kg, CI +1.75; +7.74kg, p=0.008), matched by reduced fat mass (MAD -4.34kg, CI -6.65; -2.04, p<0.001). Total bone mass increased (MAD +0.08kg, CI +0.01; +0.15kg, p=0.009) as did bone mineral density at the femoral neck (MAD +0.287 points, CI +0.140; +0.434, p<0.001). Haemoglobin was higher with testosterone therapy (MAD +10.2g/L, CI +1.50; +18.9g/L, p=0.041) and HbA1c lower (MAD -0.35%, CI -0.05; -0.54, p=0.028). Mortality was non-significantly lower in testosterone-treated patients (16% vs 25.5%, p=0.352). There was no increase in adverse events in testosterone-treated subjects. Testosterone therapy in men with cirrhosis and low serum testosterone safely increases muscle mass, bone mass and haemoglobin, and reduces fat mass and HbA1c. This is the first evidence-based therapy for sarcopenia in cirrhosis and thus requires larger-scale investigation into its potential impact on mortality. Both low testosterone and muscle wasting are associated with increased risk of death in men with severe liver disease. Administering testosterone to men with liver disease who have low testosterone levels significantly increases their muscle mass. In addition, testosterone has non-muscle beneficial effects which may be able to increase survival in this population.
Liver transplant outcome has improved considerably as a direct result of optimized surgical and anesthesiological techniques and organ allocation programs. As there is still a shortage of human organs, strict selection of transplant candidates remains of paramount importance. Recently, CT-assessed low skeletal muscle mass (i.e., sarcopenia) was identified as a novel prognostic parameter to predict outcome in liver transplant candidates. A systematic review and meta-analysis on the impact of CT-assessed skeletal muscle mass on outcome in liver transplant candidates were performed according to the PRISMA-guidelines. Nineteen studies, including 3803 patients in partly overlapping cohorts, fulfilled the inclusion criteria. The prevalence of sarcopenia ranged from 22.2-70%. An independent association between low muscle mass and post-transplantation and waiting list mortality was described in four of the six and six of the eleven studies, respectively. The pooled hazard ratios of sarcopenia were 1.84 (95% CI 1.11-3.05, p=0.02) and 1.75 (95% CI 0.99-3.00, p=0.05), for post-transplantation and waiting list mortality, respectively, independent of Model for End-stage Liver Disease (MELD) score. Less consistent evidence suggested a higher complication rate, particularly infections, in sarcopenic patients. In conclusion, sarcopenia is an independent predictor for outcome in liver transplantation patients and could be used for risk assessment.