Sarcopenia Is Associated With Development of Acute-on-Chronic Liver Failure in Decompensated Liver Cirrhosis Receiving Transjugular Intrahepatic Portosystemic Shunt

Abstract

Introduction: Muscle mass has been shown to be a prognostic marker in patients with liver cirrhosis. Transversal psoas muscle thickness normalized by height (TPMT/height) obtained by routine computed tomography is a simple surrogate parameter for sarcopenia. TPMT/height, however, is not sex specific, which might play a role in risk stratification. Its association with acute-on-chronic liver failure (ACLF) has not been established yet. ACLF is associated with systemic inflammatory dysregulation. This study aimed at evaluating the role of sarcopenia in ACLF development of patients with decompensated cirrhosis receiving transjugular intrahepatic portosystemic shunt (TIPS) using sex-specific TPMT/height.

Methods: One hundred eighty-six patients from the prospective Non-invasive Evaluation Program for TIPS and Follow Up Network cohort (observational, real-world TIPS cohort with structured follow-up) were analyzed. TPMT/height was measured from routine computed tomography. The sex-specific cutoff was determined to classify patients as sarcopenic and nonsarcopenic for 1-year mortality after TIPS. Clinical outcome was compared. Primary end points were ACLF and 1-year mortality after TIPS. Secondary end points were development of decompensations (hepatic encephalopathy and ascites) after TIPS.

Results: The sex-specific cutoff increases the diagnostic accuracy with regard to primary and secondary end points compared with the unisex cutoff. Sex-specific sarcopenia classification is an independent predictor of 1-year mortality and ACLF development in patients with cirrhosis receiving TIPS. Patients in the sarcopenia group showed significantly higher rates of mortality, ascites, overt hepatic encephalopathy, and ACLF after TIPS compared with the nonsarcopenia group. The Chronic Liver Failure Consortium Acute Decompensation score as a marker of systemic inflammation was significantly higher in sarcopenic patients.

Conclusions: This study demonstrates for the first time that sarcopenia is related to ACLF development and systemic inflammation. The prognostic value of TPMT/height can be improved by using sex-specific cutoffs. ClinicalTrials.gov identifier: NCT03584204.

Figure 1.

(a) Kaplan-Meier curve for 1-year survival stratified by unisex and sex-specific sarcopenia classification. (b) Kaplan-Meier curve for development of nonfatal acute-on-chronic liver failure (ACLF) at 2-year follow-up stratified by unisex and sex-specific sarcopenia classification. (c) Kaplan-Meier curve for development of fatal ACLF at 2-year follow-up stratified by unisex and sex-specific sarcopenia classification. CLIF-C-AD, Chronic Liver Failure Consortium Acute Decompensation; HE, hepatic encephalopathy; MELD, model of end-stage liver disease.

Figure 2.

(a) Cumulative hazard function for the presence of ascites (persistence and/or reoccurrence) after TIPS stratified by unisex and sex-specific sarcopenia classification. (b) Cumulative hazard function for the occurrence of episode of hepatic encephalopathy after TIPS stratified by unisex and sex-specific sarcopenia classification. (c) Diagram showing changes in prognostic scores before and after TIPS. ACLF, acute-on-chronic liver failure; TPMT, thickness normalized by height.