Evaluating sarcopenia in patients with cirrhosis: The role of muscle function

Effect of sarcopenia on survival in patients with cirrhosis: A meta-analysisJournal of HepatologyVol. 76Issue 3PreviewThe association between sarcopenia and prognosis in patients with cirrhosis remains to be determined. In this study, we aimed to quantify the association between sarcopenia and the risk of mortality in patients with cirrhosis, stratified by sex, underlying liver disease etiology, and severity of hepatic dysfunction. Full-Text PDF Open AccessReply to: “Evaluating sarcopenia in patients with cirrhosis: The role of muscle function”Journal of HepatologyVol. 77Issue 2PreviewWe would like to thank Xiong et al.1 for their interest in our study.2 They suggested that the assessment of sarcopenia should include muscle strength or physical performance, rather than muscle mass only, based on the revised European consensus on sarcopenia in older people (EWGSOP2) and several studies.1 Full-Text PDF We read with great interest the study by Tiantai et al., wherein they investigated the association between sarcopenia and prognosis in patients with cirrhosis.[1]Tantai X. Liu Y. Yeo Y.H. Praktiknjo M. Mauro E. Hamaguchi Y. et al.Effect of sarcopenia on survival in patients with cirrhosis: a meta-analysis.J Hepatol. 2022; 76: 588-599Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Twenty-two studies, including 6,965 patients with cirrhosis, were included in this systematic review and meta-analysis. The present study indicated sarcopenia is independently related to a 2-fold higher risk of mortality in patients with cirrhosis.[1]Tantai X. Liu Y. Yeo Y.H. Praktiknjo M. Mauro E. Hamaguchi Y. et al.Effect of sarcopenia on survival in patients with cirrhosis: a meta-analysis.J Hepatol. 2022; 76: 588-599Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The authors should be congratulated for performing a comprehensive and updated meta-analysis to evaluate the effect of sarcopenia on survival in patients with cirrhosis. Despite the strengths of this study, several issues warrant further discussion.Sarcopenia originally referred to the aging-related loss of skeletal muscle mass.[2]Yang M. Shen Y. Tan L. Li W. Prognostic value of sarcopenia in lung cancer: a systematic review and meta-analysis.Chest. 2019; 156: 101-111Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar However, most international groups, such as the European Working Group on Sarcopenia in Older People (EWGSOP), currently agree that sarcopenia should be defined not only according to the loss of skeletal muscle mass but also the decline in muscle strength (usually measured by handgrip strength) and/or physical performance (usually measured by gait speed).[3]Cruz-Jentoft A.J. Bahat G. Bauer J. Boirie Y. Bruyère O. Cederholm T. et al.Sarcopenia: revised European consensus on definition and diagnosis.Age Ageing. 2019; 48: 16-31Crossref PubMed Scopus (3838) Google Scholar Specifically, sarcopenia is probable when low muscle strength is detected; the diagnosis is confirmed by the presence of low muscle quantity or quality. In the latest EWGSOP guideline, low muscle strength overtakes the role of low muscle mass as a principal determinant of sarcopenia.[3]Cruz-Jentoft A.J. Bahat G. Bauer J. Boirie Y. Bruyère O. Cederholm T. et al.Sarcopenia: revised European consensus on definition and diagnosis.Age Ageing. 2019; 48: 16-31Crossref PubMed Scopus (3838) Google Scholar This conceptual framework has been widely recognized in the field of geriatric research. Authors should consider using the presence of both low muscle mass and low muscle function to define sarcopenia. Recent research indicated that muscle function evaluated by gait speed is an independent risk factor for mortality in patients with cirrhosis.[4]Deng Y. Lin L. Fan X. Cui B. Hou L. Zhao T. et al.Incorporation of frailty estimated by gait speed within MELD-Na and the predictive potential for mortality in cirrhosis.Ther Adv Chronic Dis. 2020; 11 (2040622320922023)Crossref PubMed Scopus (6) Google Scholar,[5]Soto R. Díaz L.A. Rivas V. Fuentes-López E. Zalaquett M. Bruera M.J. et al.Frailty and reduced gait speed are independently related to mortality of cirrhotic patients in long-term follow-up.Ann Hepatol. 2021; 25: 100327Crossref PubMed Scopus (9) Google Scholar Two other studies from Japan and the United States showed that reduced handgrip strength, rather than skeletal muscle volumes, is related to an increased risk of mortality in patients with cirrhosis.[6]Hanai T. Shiraki M. Imai K. Suetsugu A. Takai K. Moriwaki H. et al.Reduced handgrip strength is predictive of poor survival among patients with liver cirrhosis: a sex-stratified analysis.Hepatol Res. 2019; 49: 1414-1426Crossref PubMed Scopus (30) Google Scholar,[7]Wang C.W. Feng S. Covinsky K.E. Hayssen H. Zhou L.Q. Yeh B.M. et al.A comparison of muscle function, mass, and quality in liver transplant candidates: results from the functional assessment in liver transplantation study.Transplantation. 2016; 100: 1692-1698Crossref PubMed Scopus (82) Google Scholar A prospective study conducted in Romania showed that sarcopenia evaluated according to the criteria of EWGSOP is significantly associated with increased 6-month and 1-year mortality.[8]Topan M.M. Sporea I. Dănilă M. Popescu A. Ghiuchici A.M. Lupuşoru R. et al.Impact of sarcopenia on survival and clinical outcomes in patients with liver cirrhosis.Front Nutr. 2021; 8: 766451Crossref PubMed Scopus (3) Google Scholar Therefore, in order to comprehensively determine the potential effect of various sarcopenia criteria on the risk of mortality in patients with cirrhosis, the authors should perform subgroup analyses based on various criteria (e.g. only muscle mass/both muscle mass and muscle function). However, the authors analyzed the impact of low skeletal muscle mass only. They should at least explain in the discussion section of the meta-analysis that one major limitation of this study was that they were unable to collect information about muscle strength or physical performance, which is another factor defining sarcopenia.In conclusion, although the authors are to be congratulated on their hard work, the relationship between sarcopenia assessed via the EWGSOP criteria and prognosis in patients with cirrhosis still seems unclear. We strongly recommend future studies to assess the potential causal relationship, considering both muscle mass and muscle function.Financial supportThis work was supported by grants from the National Natural Science Foundation of China ( 81772642 ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. No additional external funding received for this study.Authors' contributionsJianping Xiong conceived the study and wrote the manuscript. Jianping Xiong searched the database, reviewed the studies and collected the data. Yantao Tian performed revision of the manuscript. All authors have read and approved the final manuscript. We read with great interest the study by Tiantai et al., wherein they investigated the association between sarcopenia and prognosis in patients with cirrhosis.[1]Tantai X. Liu Y. Yeo Y.H. Praktiknjo M. Mauro E. Hamaguchi Y. et al.Effect of sarcopenia on survival in patients with cirrhosis: a meta-analysis.J Hepatol. 2022; 76: 588-599Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Twenty-two studies, including 6,965 patients with cirrhosis, were included in this systematic review and meta-analysis. The present study indicated sarcopenia is independently related to a 2-fold higher risk of mortality in patients with cirrhosis.[1]Tantai X. Liu Y. Yeo Y.H. Praktiknjo M. Mauro E. Hamaguchi Y. et al.Effect of sarcopenia on survival in patients with cirrhosis: a meta-analysis.J Hepatol. 2022; 76: 588-599Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The authors should be congratulated for performing a comprehensive and updated meta-analysis to evaluate the effect of sarcopenia on survival in patients with cirrhosis. Despite the strengths of this study, several issues warrant further discussion. Sarcopenia originally referred to the aging-related loss of skeletal muscle mass.[2]Yang M. Shen Y. Tan L. Li W. Prognostic value of sarcopenia in lung cancer: a systematic review and meta-analysis.Chest. 2019; 156: 101-111Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar However, most international groups, such as the European Working Group on Sarcopenia in Older People (EWGSOP), currently agree that sarcopenia should be defined not only according to the loss of skeletal muscle mass but also the decline in muscle strength (usually measured by handgrip strength) and/or physical performance (usually measured by gait speed).[3]Cruz-Jentoft A.J. Bahat G. Bauer J. Boirie Y. Bruyère O. Cederholm T. et al.Sarcopenia: revised European consensus on definition and diagnosis.Age Ageing. 2019; 48: 16-31Crossref PubMed Scopus (3838) Google Scholar Specifically, sarcopenia is probable when low muscle strength is detected; the diagnosis is confirmed by the presence of low muscle quantity or quality. In the latest EWGSOP guideline, low muscle strength overtakes the role of low muscle mass as a principal determinant of sarcopenia.[3]Cruz-Jentoft A.J. Bahat G. Bauer J. Boirie Y. Bruyère O. Cederholm T. et al.Sarcopenia: revised European consensus on definition and diagnosis.Age Ageing. 2019; 48: 16-31Crossref PubMed Scopus (3838) Google Scholar This conceptual framework has been widely recognized in the field of geriatric research. Authors should consider using the presence of both low muscle mass and low muscle function to define sarcopenia. Recent research indicated that muscle function evaluated by gait speed is an independent risk factor for mortality in patients with cirrhosis.[4]Deng Y. Lin L. Fan X. Cui B. Hou L. Zhao T. et al.Incorporation of frailty estimated by gait speed within MELD-Na and the predictive potential for mortality in cirrhosis.Ther Adv Chronic Dis. 2020; 11 (2040622320922023)Crossref PubMed Scopus (6) Google Scholar,[5]Soto R. Díaz L.A. Rivas V. Fuentes-López E. Zalaquett M. Bruera M.J. et al.Frailty and reduced gait speed are independently related to mortality of cirrhotic patients in long-term follow-up.Ann Hepatol. 2021; 25: 100327Crossref PubMed Scopus (9) Google Scholar Two other studies from Japan and the United States showed that reduced handgrip strength, rather than skeletal muscle volumes, is related to an increased risk of mortality in patients with cirrhosis.[6]Hanai T. Shiraki M. Imai K. Suetsugu A. Takai K. Moriwaki H. et al.Reduced handgrip strength is predictive of poor survival among patients with liver cirrhosis: a sex-stratified analysis.Hepatol Res. 2019; 49: 1414-1426Crossref PubMed Scopus (30) Google Scholar,[7]Wang C.W. Feng S. Covinsky K.E. Hayssen H. Zhou L.Q. Yeh B.M. et al.A comparison of muscle function, mass, and quality in liver transplant candidates: results from the functional assessment in liver transplantation study.Transplantation. 2016; 100: 1692-1698Crossref PubMed Scopus (82) Google Scholar A prospective study conducted in Romania showed that sarcopenia evaluated according to the criteria of EWGSOP is significantly associated with increased 6-month and 1-year mortality.[8]Topan M.M. Sporea I. Dănilă M. Popescu A. Ghiuchici A.M. Lupuşoru R. et al.Impact of sarcopenia on survival and clinical outcomes in patients with liver cirrhosis.Front Nutr. 2021; 8: 766451Crossref PubMed Scopus (3) Google Scholar Therefore, in order to comprehensively determine the potential effect of various sarcopenia criteria on the risk of mortality in patients with cirrhosis, the authors should perform subgroup analyses based on various criteria (e.g. only muscle mass/both muscle mass and muscle function). However, the authors analyzed the impact of low skeletal muscle mass only. They should at least explain in the discussion section of the meta-analysis that one major limitation of this study was that they were unable to collect information about muscle strength or physical performance, which is another factor defining sarcopenia. In conclusion, although the authors are to be congratulated on their hard work, the relationship between sarcopenia assessed via the EWGSOP criteria and prognosis in patients with cirrhosis still seems unclear. We strongly recommend future studies to assess the potential causal relationship, considering both muscle mass and muscle function. Financial supportThis work was supported by grants from the National Natural Science Foundation of China ( 81772642 ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. No additional external funding received for this study. This work was supported by grants from the National Natural Science Foundation of China ( 81772642 ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. No additional external funding received for this study. Authors' contributionsJianping Xiong conceived the study and wrote the manuscript. Jianping Xiong searched the database, reviewed the studies and collected the data. Yantao Tian performed revision of the manuscript. All authors have read and approved the final manuscript. Jianping Xiong conceived the study and wrote the manuscript. Jianping Xiong searched the database, reviewed the studies and collected the data. Yantao Tian performed revision of the manuscript. All authors have read and approved the final manuscript. The authors declare that they have no conflict of interest. Please refer to the accompanying ICMJE disclosure forms for further details. 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