Malnutrition, Frailty, and Sarcopenia in Patients With Cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

Abstract

This is the first American Association for the Study of Liver Diseases (AASLD) Practice Guidance on the management of malnutrition, frailty, and sarcopenia in patients with cirrhosis. This guidance represents the consensus of a panel of experts after a thorough review and vigorous debate of the literature published to date, incorporating clinical experience and common sense to fill in the gaps when appropriate. Our goal was to offer clinicians pragmatic recommendations that could be implemented immediately in clinical practice to target malnutrition, frailty, and sarcopenia in this population. This AASLD Guidance document differs from AASLD Guidelines, which are supported by systematic reviews of the literature, formal rating of the quality of the evidence and strength of the recommendations, and, if appropriate, meta-analysis of results using the Grading of Recommendations Assessment Development and Evaluation system. In contrast, this Guidance was developed by consensus of an expert panel and provides guidance statements based on formal review and analysis of the literature on the topics, with oversight Accepted ArticleThis article is protected by copyright. All rights reserved provided by the AASLD Practice Guidelines Committee at all stages of Guidance development. The AASLD Practice Guidelines Committee chose to perform a Guidance on this topic because a sufficient number of randomized controlled trials (RCTs) were not available to support the development of a Guideline. Definitions of Malnutrition, Frailty, and Sarcopenia and Their Relationship in Patients With CirrhosisCirrhosis is a major predisposing condition for the development of malnutrition, frailty, and sarcopenia.Multiple, yet complementary, definitions of these conditions exist in the published domain outside of the field of hepatology, but consensus definitions have not yet been established by the AASLD for patients with cirrhosis. Furthermore, there has been ambiguity related to operationalization of these constructs in clinical practice. To address this, we offer definitions of the theoretical constructs of malnutrition, frailty, and sarcopenia as commonly represented in all populations, partnered with operational definitions, developed by consensus, to facilitate pragmatic implementation of these constructs in clinical practice as applied to patients with cirrhosis (Table 1). Malnutrition is a clinical syndrome that results from "an imbalance (deficiency or excess) of nutrients that causes measurable adverse effects on tissue/body form (body shape, size, composition) or function, and/or clinical outcome." 1 Key to this definition is the recognition that malnutrition represents a spectrum of nutritional disorders across the entire range of body mass index (BMI)from underweight to obese. By this definition, malnutrition leads to adverse physical effects, which, in patients with cirrhosis, are commonly manifested phenotypically as frailty or sarcopenia. Frailty has most commonly been defined as a clinical state of decreased physiologic reserve...

Letter: patients who have both sarcopenia and frailty have similar prognosis to those with either condition separately—authors’ reply

“…The recommended SMI cut-off for diagnosing sarcopenia is <50 cm 2 /m 2 in men, and 39 cm 2 /m 2 in women, as they have shown to be well correlated with increased waitlist mortality. 2,3,6 Notably, these cutoffs are different from those in non-cirrhotic patients and may be different from Asian patients with cirrhosis. 7 Bedside tools, such as handgrip strength and mid-arm muscle circumference, are readily available for use in clinical practice.…”

“…1 However, it is unclear if they used skeletal muscle index (SMI) assessment by CT scan with liver-specific cut-offs as the diagnosis tool for sarcopenia, as recommended by the recent US and European consensus documents. 2,3 The European Working Group on Sarcopenia in Older People (EWGSOP-2) also recommends assessment of sarcopenia with bedside tools such as handgrip strength, gait speed and short physical performance battery. 4 As sarcopenia and frailty partly overlap, studies evaluating outcomes of both, or either condition alone, should focus on the precise diagnosis of both conditions.…”

“…4 However, recent studies in patients with cirrhosis have investigated sarcopenia and its outcomes using measures of muscle mass alone. 3,5 SMI by CT scan is currently recommended by US and European guidelines as the most consistent and reproducible method to quantify muscle mass in patients with cirrhosis. The recommended SMI cut-off for diagnosing sarcopenia is <50 cm 2 /m 2 in men, and 39 cm 2 /m 2 in women, as they have shown to be well correlated with increased waitlist mortality.…”

“…However, there are currently insufficient data to support their use to diagnose sarcopenia accurately in patients with cirrhosis. 3,5 For research studies, the prognostic implication of either sarcopenia or frailty alone, and their co-existence, needs to be further evaluated by liver-specific assessment in a larger population. While awaiting further data, systematic assessment of frailty and/or sarcopenia in all patients with cirrhosis using a standardised instrument is recommended in clinical practice.…”

“…While awaiting further data, systematic assessment of frailty and/or sarcopenia in all patients with cirrhosis using a standardised instrument is recommended in clinical practice. 3 Assessment of both conditions can complement each other. Liver-specific frailty testing, such as Liver Frailty Index (cut-off: robust <3.2; pre-frail 3.2-4.3; and frail ≥4.4) 8,9 may be particularly useful for screening and follow-up in the ambulatory setting.…”