From the Guidelines
Liver cirrhosis patients with sarcopenia should be managed with a high-protein diet, late-evening snacks, and moderate physical activity, including resistance and endurance exercise, to improve muscle mass and function, as recommended by the most recent guidelines 1. The development of sarcopenia in cirrhosis results from multiple factors including malnutrition, metabolic abnormalities, reduced physical activity, and hormonal imbalances.
- Key factors contributing to sarcopenia in liver cirrhosis include:
- Malnutrition and inadequate protein intake
- Metabolic abnormalities, such as insulin resistance and glucose metabolism disorders
- Reduced physical activity and sedentary lifestyle
- Hormonal imbalances, including low testosterone levels
- Management of sarcopenia in liver cirrhosis should focus on:
- Nutritional optimization with increased protein intake of 1.2-1.5 g/kg/day, with evening supplementation of 20-40g of protein being particularly beneficial, as recommended by the EASL clinical practice guidelines on nutrition in chronic liver disease 1
- Branched-chain amino acid supplements (BCAA) at 0.25g/kg/day can help improve muscle synthesis in patients who cannot tolerate standard protein sources
- Regular resistance exercise (2-3 sessions weekly) combined with aerobic activity should be encouraged as tolerated, as it promotes an increase in skeletal muscle mass and functional capacity, as suggested by the EASL clinical practice guidelines on nutrition in chronic liver disease 1
- Addressing underlying causes like alcohol cessation is essential, as it can help reduce the risk of sarcopenia and improve overall liver function
- Early identification of sarcopenia through imaging or functional assessments is crucial, as it predicts worse outcomes, including higher mortality, increased complications, and reduced quality of life in cirrhotic patients, as highlighted by the EASL-EASD-EASO clinical practice guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD) 1.
From the Research
Definition and Prevalence of Sarcopenia in Liver Cirrhosis
- Sarcopenia is a prevalent muscle abnormality in patients with cirrhosis, affecting 25-70% of this population 2, 3, 4.
- It is characterized by severe muscle depletion and is associated with poor prognosis both pre- and post-liver transplantation 2.
Pathogenesis of Sarcopenia in Liver Cirrhosis
- The pathogenesis of sarcopenia is multifactorial, resulting from an imbalance between protein synthesis and breakdown 2.
- Factors contributing to muscle depletion in cirrhosis include hyperammonemia, increased autophagy, proteasomal activity, lower protein synthesis, and impaired mitochondrial function 2.
- Other factors involved in regulating muscle mass include cellular energy status, availability of metabolic substrates, alterations in the endocrine system, cytokines, myostatin, and exercise 2.
Diagnosis and Assessment of Sarcopenia
- Sarcopenia is commonly defined through the measurement of the skeletal muscle index of the third lumbar spine 5.
- Other parameters used to assess sarcopenia include handgrip strength, mid-arm muscle circumference, and triceps subcutaneous fat 4.
Management and Treatment of Sarcopenia
- A combination of nutritional, physical, and pharmacological interventions may be necessary to reverse sarcopenia in cirrhosis 2.
- Nutritional interventions include high protein diets (1.5 g/kg/day) with 30-40 kcal/kg/day and late-evening snacks with at least 50 g of carbohydrates 3.
- Branched-chain amino acid supplementation has been shown to improve skeletal muscle index and mid-arm muscle circumference in patients with liver cirrhosis and sarcopenia 4.
- Physical activity, such as moderate exercise, is also recommended to help manage and treat sarcopenia 2, 6.
- New pharmacological strategies, including myostatin inhibition and the nutraceutical Urolithin A, have been proposed to treat age-related sarcopenia and may also be of use in chronic liver disease 5.