Transjugular intrahepatic portosystemic shunt insertion improves muscle mass but not muscle function or frailty measures

Abstract

Introduction Sarcopenia in cirrhosis is associated with poor outcomes. While transjugular intrahepatic portosystemic shunt (TIPS) insertion improves radiological measures of muscle mass, its impact on muscle function, performance and frailty has not been evaluated. Methods Patients with cirrhosis referred for TIPS were prospectively recruited and followed for 6 months. L3 CT scans were used to calculate skeletal muscle and adipose tissue parameters. Handgrip strength, Liver Frailty Index and short physical performance battery were serially monitored. Dietary intake, insulin resistance, insulin-like growth factor (IGF)-1, and immune function using QuantiFERON Monitor (QFM) were measured. Results Twelve patients completed the study with a mean age of 58 ± 9 years and model for end-stage liver disease score of 16 ± 5. At 6 months post-TIPS, skeletal muscle area increased from 139.33 cm2 ± 22.72 to 154.64 ± 27.42 (P = 0.012). Significant increases were observed in the subcutaneous fat area (P = 0.0076) and intermuscular adipose tissue (P = 0.041), but not muscle attenuation or visceral fat. Despite marked changes in muscle mass, no improvements were observed in handgrip strength, frailty, or physical performance. At 6 months post-TIPS, IGF-1 (P = 0.0076) and QFM (P = 0.006) increased compared to baseline. Nutritional intake, hepatic encephalopathy measures, insulin resistance and liver biochemistry were not significantly impacted. Conclusion Muscle mass increased following TIPS insertion as did IGF-1, a known driver of muscle anabolism. The lack of improvement in muscle function was unexpected and may relate to impairment in muscle quality and the effects of hyperammonaemia on muscle contractile function. Improvements in QFM, a marker of immune function, may suggest a reduction in infection susceptibility in this at-risk population and requires further evaluation.

Portal Hypertension in Malnutrition and Sarcopenia in Decompensated Cirrhosis—Pathogenesis, Implications and Therapeutic Opportunities

“…Importantly, increased muscle mass post-TIPS stent has been shown to correlate with improved survival, reiterating the importance of treating sarcopenia in patients with portal hypertension [ 148 ]. In a prospective cohort study involving 12 patients, Hey et al found that muscle mass significantly improved at six months post-TIPS insertion, with the mean skeletal muscle area increasing from 139.32 ± 22.72 cm 2 to 154.64 ± 27.43 cm 2 [ 149 ].…”

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy—A Review of the Past Decade’s Literature Focusing on Incidence, Risk Factors, and Prophylaxis

“…The time course of post-TIPS HE is defined by a steep rise in HE incidence in the first month after TIPS insertion, where liver function often takes a post-procedural hit [ 29 ]. The risk of new-onset episodic or recurrent HE remains high during the first year after TIPS but with the well-known post-TIPS improvement in muscle mass and fewer stressful events, the risk seemingly stagnates or declines [ 29 , 30 , 31 , 32 , 33 , 34 ]. Most cases of post-TIPS HE respond to lactulose and rifaximin treatment, but it is noteworthy that persistent post-TIPS HE is reported in 4–10% [ 20 , 35 , 36 , 37 , 38 ].…”

“…The time course of post-TIPS HE is defined by a steep rise in HE incidence in the first month after TIPS insertion, where liver function often takes a post-procedural hit [29]. The risk of new-onset episodic or recurrent HE remains high during the first year after TIPS but with the well-known post-TIPS improvement in muscle mass and fewer stressful events, the risk seemingly stagnates or declines [29][30][31][32][33][34]. Most cases of post-TIPS HE Despite recent clinical and procedural advancements, there has been no overall trend towards a decrease in incidence over the years, as illustrated by Figure 2, where studies are ordered according to the year when patient recruitment began (Figure 2) [17][18][19][20][21][22][23][24][25][26].…”

Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management

“…Moreover, while all studies conducted have focused on sarcopenic assessment after TIPS, only one novel study has included the effect of TIPS on frailty parameters[ 218 ]. In this study, 12 cirrhosis patients showed improvement in skeletal muscle mass six months after TIPS compared to their baseline measurements before the procedure[ 218 ]. However, there was no improvement in LFI, handgrip strength, or physical performance measurements[ 218 ].…”

“…In this study, 12 cirrhosis patients showed improvement in skeletal muscle mass six months after TIPS compared to their baseline measurements before the procedure[ 218 ]. However, there was no improvement in LFI, handgrip strength, or physical performance measurements[ 218 ]. This study adds to the concerns about using TIPS as a potential therapy for cirrhotic frail patients.…”