Sarcopenia Does Not Worsen Survival After Shunting for Refractory Ascites

By David Douglas

October 29, 2020

NEW YORK (Reuters Health) - In patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites, sarcopenia is not associated with increased mortality, according to new research from the UK.

"Until now, there was concern that sarcopenia might be a contraindication of TIPS in such patients, however we were able to show that this is not the case," Dr. Emmanuel Tsochatzis of University College London told Reuters Health by email. "Conversely, placement of TIPS even improved sarcopenia in a subset of patients."

Sarcopenia is a predictor of poor outcome in patients with cirrhosis before and after transplantation, he and his colleagues note in The American Journal of Gastroenterology. But its influence on TIPS, an effective treatment for refractory ascites in selected patient, was unknown.

The researchers studied data on 107 patients who underwent TIPS insertion for refractory ascites between 2010 and 2018. They considered patients in the lowest quartile of a total psoas muscle index at the third lumbar vertebra (L3-PMI) as stratified by sex to be sarcopenic. Women and men with a skeletal muscle index at the third lumbar vertebra (L3-SMI) below 39 cm2/m2 and 50 cm2/m2, respectively, were also considered to be sarcopenic.

Patients were followed by their treating hepatologist and were seen at least every six months for a median of 14.2 months overall.

Sixty-one patients (57%) had sarcopenia. None had a history of pre-TIPS hepatic encephalopathy (HE), but 30 patients (29.9%) showed de novo HE after TIPS insertion. Medical therapy controlled the condition in 27 patients, four required TIPS reduction and one needed TIPS occlusion.

Multivariate analysis showed that only L3-SMI (hazard ratio per cm2/m2, 0.95; 95% confidence interval, 0.91 to 0.99) and platelet count (HR, 0.99; 95% CI, 0.99 to 1.00) predicted de novo HE, whereas sarcopenia did not. In addition, in patients with available repeat cross-sectional imaging, the team saw an improvement of L3-SMI over time.

Thirty-four patients died during follow-up. Multivariate analysis indicated that age, model for end-stage liver disease with sodium, and platelet count were independent predictors of mortality.

In contrast, neither L3-SMI (HR, 0.99; 95% CI, 0.96 to 1.03) nor sarcopenia (HR, 0.82; 95% CI, 0.42 to 1.62) was linked to mortality in univariate Cox regression analysis.

The researchers note that a recent study concluded that sarcopenia was associated with higher mortality post-TIPS, but that they believe "our study provides a more accurate depiction . . . and that baseline sarcopenia should not be seen as a contraindication" to TIPS because it is not associated with de novo HE or increased mortality.

SOURCE: The American Journal of Gastroenterology, online October 12, 2020.