Systematic review: the role of frailty in advanced chronic liver disease

Abstract

Background: Frailty is a known predictor of outcome and mortality in patients undergoing liver transplantation. However, most patients remain unsuitable transplant candidates. It is not yet known if the assessment of frailty in non-transplant candidates can aid prognostication. Aim: To collate and interrogate the various frailty tools presently used to predict mortality in the non-transplant cirrhosis setting. Methods: A comprehensive review of MEDLINE and EMBASE databases for articles published from inception to March 2022 was undertaken, excluding those where patients underwent transplantation or had hepatocellular carcinoma.Results: We identified 12 observational cohort studies, featuring 9 frailty indices.These were from various global healthcare settings and of fair or good quality. Most were objective tools utilising clinician-based assessments. All frailty scores predicted prognosis, with variability in the method of application, and utilisation in long-or short-term mortality. Three studies directly compared different indices in the same population. There was some evidence that simple tools could perform as well, if not better, than more complex, time-consuming scores.Conclusions: Various frailty tools can reproducibly evaluate mortality in patients with cirrhosis who are ineligible for transplant. However, further prospective headto-head comparative studies are needed. In addition to determining model utility, studies should focus on important relative considerations which may limit widespread implementation including, ease of use and limited resources, given the global disparity of liver care provision. These tools may positively identify specific patient cohorts at risk of impending deterioration, thereby stratifying those patients likely to benefit from early integration with palliative care.

The prevalence and characteristics of frailty in cirrhosis patients: a meta-analysis and systematic review

“…At the time our research is being conducted, few research studies have focused on the prevalence of frailty in cirrhosis patients. A previous meta-analysis ( 29 ) discussed the frailty assessment instruments in cirrhosis patients, including the Liver Frailty Index (LFI), the Short Physical Performance Battery, the 5-m gait speed, and routine nursing assessment, but it did not research the estimated prevalence of frailty as our study does. Currently, the most frequent tool is the LFI, which is a performance-based tool comprising three separate tests, including grip strength, chair stands, and balance testing.…”

The relationship between sarcopenia, multidimensional frailty, and malnutrition cluster and long‐term mortality in hospitalized patients with cirrhosis

“…The assessment of frailty aligns with a definition rooted in the realm of geriatrics, reflected as declining physiologic reserve and increased vulnerability to exogeneous insults 24 . Actually, physical frailty predominates in the existing literature pertinent to patients with cirrhosis, despite the fact that this phenomenon deviates from original definition of frailty as a global construct 5 . In our study, the choice of multidimensional frailty was dependent on its availability and prognosticating utility in the circumstance that hospitalized cirrhotic patients are prone to being critically ill. Intriguingly, multidimensional frailty was observed less often than malnutrition or sarcopenia, and only 46.9% (15/32) of frail subjects were also sarcopenic.…”

“…24 Actually, physical frailty predominates in the existing literature pertinent to patients with cirrhosis, despite the fact that this phenomenon deviates from original definition of frailty as a global construct. 5 In our study, the choice of multidimensional frailty was dependent on its availability and prognosticating utility in the circumstance that hospitalized cirrhotic patients are prone to being critically ill. Intriguingly, multidimensional frailty was observed less often than malnutrition or sarcopenia, and only 46.9% (15/32) of frail subjects were also sarcopenic. This phenomenon can be attributed to the conceptual framework of multidimensional frailty, covering multiple aspects like weight loss, falls, and IADL limitation, and is not solely characterized by decreased muscle function/mass.…”

“…Frailty derives from the field of geriatrics and implies that vulnerable subjects exhibit declining physical or psychological reserve in response to a wide range of health stressors. In hepatology, two common phenotypic manifestations with regard to frailty have been developed, namely, physical frailty indicative of decreased muscle contractile capability/functional performance and multidimensional frailty suggestive of accumulated health deficits 5 . Sarcopenia reflects a decrease in muscle strength and depletion in muscle mass, with the latter representing a major assessment metric in cirrhotic patients.…”

“…In hepatology, two common phenotypic manifestations with regard to frailty have been developed, namely, physical frailty indicative of decreased muscle contractile capability/ functional performance and multidimensional frailty suggestive of accumulated health deficits. 5 Sarcopenia reflects a decrease in muscle strength and depletion in muscle mass, with the latter representing a major assessment metric in cirrhotic patients. Radiologydefined modalities based on cross-sectional images (e.g., computed tomography [CT] or magnetic resonance) are routinely used to measure muscle mass in these patients.…”