Review article: malnutrition/sarcopenia and frailty in patients with cirrhosis

Background: Malnutrition/sarcopenia and frailty are common in patients with cirrhosis and are associated with poor outcomes. Aim: To provide an overview of data on the importance, assessment and management of malnutrition/sarcopenia and frailty in cirrhosis. Methods: A literature search was conducted in PubMed and other sources, using the search terms sarcopenia, muscle, malnutrition, cirrhosis, liver and frailty from inception to April 2019, to identify the relevant studies and international guidelines. Results: The prevalence of malnutrition/sarcopenia in cirrhosis is 23%-60%. Frailty generally overlaps with malnutrition/sarcopenia in cirrhosis, leading to increased morbidity and mortality. Rapid nutritional screening assessment should be performed in all patients with cirrhosis, and more specific tests for sarcopenia should be performed in those at high risk. The pathogenesis of malnutrition/sarcopenia in cirrhosis is complex/multifactorial and not just reduction in protein/calorie intake. Hyperammonemia appears to be the main driver of sarcopenia in cirrhosis through several molecular signalling pathways. Nutritional management in malnourished patients with cirrhosis should be undertaken by a multidisciplinary team to achieve adequate protein/calorie intake. While the role of branched-chained amino acids remains somewhat contentious in achieving a global benefit of decreasing mortality- and liver-related events, they, and vitamin supplements, are recommended for those with advanced liver disease. Novel strategies to reverse sarcopenia such as hormone supplementation, long-term ammonia-lowering agents and myostatin antagonists, are currently under investigation. Conclusions: Malnutrition/sarcopenia and frailty are unique, inter-related and multi-dimensional problems in cirrhosis which require special attention, prompt assessment and appropriate management as they significantly impact morbidity and mortality.