Sarcopenia associada à cirrose: abordagem integrada entre imagem, função e metabolismo na prática clínica

CAMPECHE-LEÃO, Aloma Conceição Magno; ARRUDA, Monalisa Reis; BATISTA, Ana Clara Vital; GARCEZ, Lais Spindola; JESUS, Rosangela Passos de; COTRIM, Helma Pinchemel; CAVALCANTE, Lourianne Nascimento

doi:10.1590/S0004-2803.24612026-017

person Aloma Conceição Magno CAMPECHE-LEÃO

conceptualization and design · literature review · acquisition of data · manuscript drafting · data interpretation · manuscript review · drafting the article or revising it critically for important intellectual content

schoolUniversidade Federal da Bahia, Programa de Pós-Graduação em Medicina e Saúde (PPGMS), Salvador, BA, Brasil.

0009-0006-8049-9711

person Monalisa Reis ARRUDA

data interpretation · manuscript review · drafting the article or revising it critically for important intellectual content

school Universidade Federal da Bahia, Programa de Pós Graduação em Alimentos, Nutrição e Saúde, Salvador, BA, Brasil.

0009-0003-7419-9147

person Ana Clara Vital BATISTA

data interpretation · manuscript review · drafting the article or revising it critically for important intellectual content

school Universidade Federal da Bahia, Programa de Pós Graduação em Alimentos, Nutrição e Saúde, Salvador, BA, Brasil.

0000-0001-7471-1663

person Lais Spindola GARCEZ

data interpretation · manuscript review · drafting the article or revising it critically for important intellectual content

school Universidade Federal da Bahia, Programa de Pós Graduação em Alimentos, Nutrição e Saúde, Salvador, BA, Brasil.

0000-0001-5818-9502

person Rosangela Passos de JESUS

data interpretation · manuscript review · drafting the article or revising it critically for important intellectual content

school Universidade Federal da Bahia, Programa de Pós Graduação em Alimentos, Nutrição e Saúde, Salvador, BA, Brasil.

0000-0002-2276-0452

person Helma Pinchemel COTRIM

final approval of the version to be published

schoolUniversidade Federal da Bahia, Programa de Pós-Graduação em Medicina e Saúde (PPGMS), Salvador, BA, Brasil.

0000-0001-7698-6919

person Lourianne Nascimento CAVALCANTE

conceptualization and design · literature review · acquisition of data · manuscript drafting · data interpretation · manuscript review · drafting the article or revising it critically for important intellectual content · final approval of the version to be published

schoolUniversidade Federal da Bahia, Programa de Pós-Graduação em Medicina e Saúde (PPGMS), Salvador, BA, Brasil.

0000-0003-1110-0931

personCorresponding Author: Lourianne Nascimento Cavalcante. Email:
lourianne@gmail.com

Declared conflict of interest of all authors:

none

Associate editor:

Angelo Alves de Mattos

Method	Measurement	Cutoffs	Major Advantages	Major Limitations	Prognostic	Clinical Context	Key Reference
CT (L3 Skeletal Muscle Index)	Muscle mass cross-sectional area at L3 normalized by height	Men <50 cm²/m²; women <39 cm²/m²	Gold standard; strong prognostic value; widely validated	Radiation; cost; requires software; not suitable for serial monitoring	Waitlist mortality; posttransplant mortality; complications	Liver transplant evaluation; patients undergoing CT for HCC surveillance	Carey EJ et al., Hepatology 2017
CT (Psoas or Paraspinal Muscle Area)	Segmental muscle mass	Cohortspecific percentiles	Uses existing imaging; feasible retrospectively	Lower reproducibility; less robust than total SMI	Mortality; infections; length of stay	Centers without full morphometry software	Bhanji RA et al., Hepatology 2019
DEXA	Total and appendicular lean mass	No cirrhosisspecific consensus	Low radiation; reproducible; whole-body composition	Strongly affected by ascites/edema; equipment required	Frailty; reduced physical function	Research settings; combined bone/muscle assessment	Lai JC et al., Hepatology 2017
Bioelectrical Impedance Analysis (BIA)	Estimated lean mass	Cohortspecific	Portable; inexpensive; useful for serial follow-up	Highly hydration-dependent; ascites overestimates lean mass	Moderate association with outcomes	Outpatient screening; lowresource settings	Merli M et al., Eur J Gastroenterol Hepatol 2015
MidArm Muscle Circumference (MAMC)	Peripheral muscle mass (anthropometry)	Men <24.2 cm; women <21.5 cm	Very low cost; unaffected by ascites; bedside applicability	Interobserver variability; regional cutoffs	One-year mortality; functional decline	Resourcelimited settings; routine screening	Saueressig MG et al., Clin Nutr 2024
Handgrip Strength (HGS)	Muscle strength	<27 kg (men); <16 kg (women)	Simple; inexpensive; strong predictor of mortality	Does not measure mass; requires cooperation	Mortality; hospitalization; frailty	Screening; pretransplant evaluation	Ha J et al., Liver Int 2018
Short Physical Performance Battery (SPPB)	Physical performance	<8 points	Integrates balance, gait, and strength; strong prognostic value	Requires space/time; less specific to muscle	Mortality; falls; hospitalization	Frailty assessment; transplant evaluation	Kirk A et al., J Hepatol 2024
Six-minute Walk Test (6MWT)	Functional capacity	<250-300 m	Reflects global functional reserve; responsive to interventions	Influenced by cardiopulmonary disease	Hospitalization; mortality	Exercise programs; pretransplant assessment	Lin S et al., J Hepatol 2022
Liver Frailty Index (LFI)	Composite frailty score	≥4.5-4.6	Validated; superior to MELD for waitlist mortality	Does not measure muscle mass	Waitlist mortality; hospitalization	Transplant candidate evaluation	Lai JC et al., Hepatology 2017
Ultrasound (Quadriceps Thickness)	Peripheral muscle mass	No validated cutoffs	No radiation; portable; repeatable	Operatordependent; limited validation	Correlates with CT and strength	Research; centers with expertise	Nishikawa H et al., J Gastroenterol Hepatol 2021

Intervention	Intervention	Population	Study Design	Outcomes	Main Findings	Key Limitations	Key Reference
Supervised Resistance Training	Exercise (strength + aerobic)	Compensated cirrhosis (Child A/B)	Small randomized trials (8-16 weeks)	Muscle mass, strength, VO², quality of life	↑ strength, ↑ lean mass, ↑ aerobic capacity; safe	Small samples; heterogeneous protocols; limited data in Child C	Berzigotti A et al., J Hepatol 2017
Multimodal Prehabilitation (Exercise + Nutrition)	Integrated rehabilitation	Pretransplant candidates	Prospective cohorts	Frailty, LFI, hospitalization, transplant readiness	Improved physical performance; possible reduction in admissions	No large RCTs; heterogeneous interventions	Aamann L et al., Liver Int 2020
HighProtein Diet (1.2-1.5 g/kg/day)	Nutritional optimization	Compensated and decompensated cirrhosis	Clinical trials and cohorts	Nitrogen balance, lean mass, HE	Improved nitrogen balance; no worsening of HE	Variable adherence; heterogeneous diets	ESPEN Guidelines 2020; Bunchorntavakul C, Clin Liver Dis 2020
LateEvening Snack	Meal timing intervention	Cirrhotics at nutritional risk	Small clinical trials	Substrate oxidation, nitrogen balance	Reduced nocturnal catabolism; improved protein balance	Small studies; surrogate outcomes	Tsien C et al., Hepatology 2012
Oral BranchedChain Amino Acids (BCAAs)	Amino acid supplementation	Cirrhotics with HE or sarcopenia	RCTs; Cochrane metaanalysis	HE, quality of life, muscle mass, survival	Modest improvement in HE/QoL; inconsistent muscle effects	Heterogeneous formulations; adherence issues	Gluud LL et al., Cochrane 2017
PlantBased Protein Diet	Protein source modulation	Cirrhotics with HE	Small crossover trials	HE, ammonia, protein tolerance	Better tolerance; possible ammonia reduction	Small samples; limited muscle outcomes	Iqbal U et al., Nutr Rev 2021
Testosterone Replacement (Hypogonadal Men)	Hormonal therapy	Men with cirrhosis and hypogonadism	Small RCTs	Lean mass, strength, bone density	↑ lean mass and bone density	Safety concerns (fluid retention, HCC risk)	Sinclair M et al., Clin Endocrinol 2016
AmmoniaLowering Agents (Lactulose, Rifaximin, LOLA)	Metabolic modulation	Cirrhotics with HE; animal models for muscle	RCTs for HE; preclinical for muscle	HE, ammonia, muscle mass (animals)	Improved HE; rifaximin+LOLA↑ muscle mass in animals	No human trials with muscle endpoints	Kumar A et al., Hepatology 2017
Myostatin Inhibitors / ActRII Antibodies	Experimental anabolic therapy	Noncirrhotic chronic disease populations	Phase II/III trials	Muscle mass, function	↑ muscle mass; inconsistent functional gains	No cirrhosis data; safety concerns	Bhanji RA et al., Hepatology 2019
Selective Androgen Receptor Modulators (SARMs)	Experimental anabolic therapy	Older adults, COPD, cancer	Phase II trials	Lean mass, strength	↑ lean mass; inconsistent strength effects	No cirrhosis data; hepatotoxicity risk	General sarcopenia reviews (no cirrhosis trials)
Structured PreTransplant Prehabilitation	Multimodal intervention	Liver transplant candidates	Cohort studies	LFI, hospital stay, posttransplant recovery	Improved LFI; possible shorter hospitalization	No RCTs; heterogeneous programs	Tandon P et al., J Hepatol 2021

[TFN1] CT: computed tomography. SMI: skeletal muscle index. DEXA: dual-energy X-ray absorptiometry. BIA: bioelectrical impedance analysis. MAMC: mid-arm muscle circumference. HGS: handgrip strength. SPPB: short physical performance battery. 6MWT: six-minute walk test. LFI: liver frailty index. HCC: hepatocellular carcinoma.