Frailty in advanced liver disease

Abstract

Prognostication of patients with cirrhosis is complex, depending on more than just the severity of liver disease. Scores such as the model for end-stage liver disease (MELD) and Child Pugh can assist with prognostication, yet by focusing on physiological parameters they fail to completely capture the elements contributing to a patient's clinical status. Evidence is increasing to support an important role for physical functioning in patient outcomes. Frailty has been increasingly recognised in medical literature over recent years, including in hepatology where it is identified in nearly half of cirrhosis patients. It is a complex construct consisting of multisystemic physiological decline and increased vulnerability to stressors. Diagnosis is complicated by lack of a consensus definition and measurement tool for frailty in cirrhosis. Frailty heralds a poor prognosis, predicting increased morbidity and mortality both pre- and postliver transplant, independent of MELD score. It is thought to be reversible, with promising data supporting prehabilitation and lifestyle intervention programs. In the future, assessment of patients with cirrhosis is likely to incorporate a measure of frailty, however, further research is required.

A Systematic Review of Medical Nutrition Therapy Guidelines for Liver Cirrhosis: Do We Agree?

“…Overall, adequate nutrition is pivotal in cirrhosis management to combat malnutrition and infections, which synergistically contribute to 65% of mortality among cirrhotic patients . In particular, adequate protein intake must be ensured to prevent sarcopenia, which has been shown to increase the risk for frailty, osteoporosis, and mortality among cirrhotic patients …”

“…The KASL guidelines were the only ones advocating for salt reduction below 5 g/d, whereas the EASL suggested the daily consumption of 4.6–6.9 g of salt. However, debate has arisen on whether the pros and cons of salt‐restrictive diets (<5–6 g/day) have been adequately weighed, as they are associated with an impaired food taste, resulting in PEM, sarcopenia, and frailty . A common problem to consider in sodium reduction, however, is that cirrhosis care often involves different healthcare providers who are not coordinated centrally, with many controversial recommendations being suggested by each one, resulting in reduced patient care and quality of life .…”

Frailty Assessment in Patients with Liver Cirrhosis

“…The underlying pathophysiology of frailty in liver disease is not completely understood. However, it is anticipated that frailty is a result of a multitude of dysfunctional organ systems including neuromuscular, endocrine, immune, and skeletal muscle (Table ) . Frailty and sarcopenia have been used interchangeably in the past; however, frailty should remain independent from sarcopenia .…”

“…However, it is anticipated that frailty is a result of a multitude of dysfunctional organ systems including neuromuscular, endocrine, immune, and skeletal muscle (Table ) . Frailty and sarcopenia have been used interchangeably in the past; however, frailty should remain independent from sarcopenia . Sarcopenia is thought to represent an earlier phenotype that progresses to a systemic disturbance of frailty, which encompasses psychological, social, and other environmental factors .…”

“…Refer to Table to compare and contrast frailty and sarcopenia. The prevalence rate of frailty in patients awaiting liver transplant (LT) ranges from 17% to 49% depending on diagnostic and inclusion criteria (Table ) …”