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©The Author(s) 2023.
World J Gastroenterol. Dec 14, 2023; 29(46): 6028-6048
Published online Dec 14, 2023. doi: 10.3748/wjg.v29.i46.6028
Published online Dec 14, 2023. doi: 10.3748/wjg.v29.i46.6028
Table 2 Pathophysiology, effects, and management recommendations for frailty predisposing factors in cirrhosis
Predisposing factor | Pathophysiology | Morbidity and mortality | Recommendations |
Ascites | Loss of appetite; Difficult ambulation; Reduced stomach capacity; Poor digestion | Odds of frailty were higher in ascitic than non-ascitic patients [adjusted odd ratio 1.56, 95% confidence interval (CI): 1.15-2.14][129]. Ascitic patients identified as frail had a 29% waitlist mortality rate, higher than the 17% rate for non-frail patients[129] | Large volume paracentesis with iv albumin; Salt intake not < 5 g NaCl/d to preserve food palatability |
Hepatic encephalopathy (HE) | Decreased voluntary oral intake; Decreased capacity for ambulance and exercise | Odds of frailty were higher in HE than in non-HE patients (odd ratio 2.45, 95%CI: 1.80-3.33)[129]. Waitlist mortality was higher for HE patients identified as frail (30%) than non-frail (20%)[129] | Enteral nutrition with precautions to avoid aspiration and hyperglycemia; Parenteral nutrition if indicated; Avoid unnecessary protein restriction |
Alcohol intake | Decreased oral intake; Gastrointestinal upset; Vitamin and mineral deficiency; Increased resting energy expenditure; Alcohol direct toxic muscular and neurologic effects | Frail alcoholic liver disease patients had a significantly higher risk of death or liver transplantation compared to non-frail patients (P < 0.001)[130] | Alcohol abstinence; Healthy diet with approximately 30 kcal/kg to 40 kcal/kg per day; Small and frequent meals; Enteral feeding in severe disease |
Sarcopenic obesity | Challenging to diagnose; Physical disability due to decreased muscle size and high muscle fat | MASLD cirrhotic patients have an increased risk of worsening frailty over time and higher waitlist mortality than non-MASLD patients[131] | Structured exercise program to help preserve muscle mass; If caloric restriction is necessary, maintain adequate protein intake (1.2-1.5 g/kg/d) |
Prolonged fasting | Accelerated catabolic state with Increased muscle breakdown | Limit fasting period to a maximum of 12 h; Daily calorie intake should be divided into 4-6 meals; Late evening snacks | |
Loop diuretics | May worsen muscle mass loss | Loop diuretics inversely correlated with skeletal muscle mass in cirrhotic patients | Regular frailty assessments are recommended for patients who have been on prolonged courses of loop diuretics, particularly when the dosage exceeds 20 mg/d; Spironolactone may be a preferable option for long-term use due to its promising efficacy in treating sarcopenia |
Aging | Combined muscle loss due to aging and hepatic illness (compound sarcopenia) | Elderly sarcopenic patients with cirrhosis have longer hospital stays, higher hospitalization costs, and increased risk of in-hospital mortality[15] | Frequent frailty assessment and management in elderly patients with cirrhosis |
- Citation: Elsheikh M, El Sabagh A, Mohamed IB, Bhongade M, Hassan MM, Jalal PK. Frailty in end-stage liver disease: Understanding pathophysiology, tools for assessment, and strategies for management. World J Gastroenterol 2023; 29(46): 6028-6048
- URL: https://www.wjgnet.com/1007-9327/full/v29/i46/6028.htm
- DOI: https://dx.doi.org/10.3748/wjg.v29.i46.6028