COMMENTARY

Advice for Combating Frailty's Fatal Impact in Liver Disease

Rowen K. Zetterman, MD

Disclosures

January 22, 2018

Possible Advantages of Activity and Testosterone

Patients on the transplant list are often sedentary (76%) or have light physical activity (19%), with only 5% spending time in moderate or vigorous activity.[33] Ensuring adequate physical activity in patients with cirrhosis is important. Simple clinical assessment of physical activity underestimates actual physical activity,[33] which is often reduced in patients with cirrhosis,[34] adding to findings of muscle weakness and frailty.

Improving physical activity may even reduce some complications of cirrhosis. In patients with cirrhosis, increased physical activity coupled with adequate nutrition reduced the hepatic venous pressure gradient compared with just nutritional therapy.[35] A decrease in portal pressure has been observed with body weight reduction after an intensive program of exercise in obese patients with cirrhosis.[36]

Testosterone levels are reduced in the majority of men with cirrhosis,[37] with levels typically decreasing as cirrhosis worsens. Low testosterone levels in cirrhosis may be an independent predictor of increased mortality or need for liver transplantation.[38] Application of testosterone gel to a small series of male patients with cirrhosis increased muscle strength and reduced evidence of gynecomastia.[39] In addition, a double-blind, placebo-controlled trial of intramuscular testosterone improved lean muscle mass, total bone mass, and bone mineral density, and produced higher hemoglobin levels and lower A1c levels in male patients with cirrhosis.[40]

Summary

Prevention of malnutrition, sarcopenia, and frailty in patients with advanced liver disease is important.

Adequate nutrition should be ensured through provision of a diet of 40 kcal/kg/day, use of frequent small meals, separation of liquids from solid foods to allow greater caloric food volumes, offering of a nighttime snack between midnight and 7 AM, and use of enteral feeding when necessary.

Maintaining physical activity may also reduce frailty. Patients should be encouraged to walk at least 5000 steps daily and use daily resistance training.

The role of testosterone needs additional studies, given the potential risk of anabolic steroids and the development of hepatocellular carcinoma.

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