Clin Mol Hepatol > Volume 29(1); 2023 > Article
Song, Chang, and Yang: Letter regarding “Impacts of muscle mass dynamics on prognosis of outpatients with cirrhosis”
Dear Editor,
Sarcopenia refers to progressive decline in skeletal muscle, function, and strength with advancing age [1]. Sarcopenia is also highly prevalent in patients with cirrhosis [2,3], and the development of sarcopenia in cirrhosis is considered to be associated with systemic inflammation [4,5]. In addition, sarcopenia has been reported to be associated with adverse clinical outcomes, such as cirrhotic complications, waitlist mortality, and post-transplantation mortality [3,6,7]. For these reasons, the importance of assessment of sarcopenia in patients with cirrhosis is being emphasized [8-10]. However, there are few studies on the association between changes in sarcopenia and the prognosis of cirrhosis. Thus, we read with great interest the article of Kim et al. [11], which described that the change in muscle mass was a good predictor of the development of cirrhotic complications independent of liver function. However, it is still necessary to consider some of the issues that were not mentioned by Kim et al. [11].
Firstly, sarcopenia has sex-specific differences. Sex-specific cutoff values are used to define sarcopenia [8], and the prevalence of sarcopenia is higher in male patients than in female patients with cirrhosis [3]. In addition, some studies have reported that the impact of sarcopenia on clinical outcomes could differ between male and female [2,12]. The sex-specific differences of sarcopenia might be caused by sex hormones, such as testosterone [13]. The rate of muscle mass reduction and the impacts of muscle mass reduction on the prognosis could vary by gender. Kim et al. [11] described that male patients had higher prevalence of sarcopenia compared to female patients, and the changes in muscle mass significantly predicted the development of complication of cirrhosis in both sex groups. However, it should be considered that change in muscle mass may not be an independent prognostic factor after adjusting Child-Pugh and Model for End-stage Liver Disease scores, if stratified by sex.
Secondly, the lifestyle of cirrhotic patients should be considered. In the study of Kim et al. [11], alcohol-related liver disease accounted for 21.0% of all patients, and was the second most common etiology. In addition, alcohol-related liver disease was an independent risk factor for the development of complication. However, there was no description of alcohol use after enrollment. With regard to alcohol-related liver disease, hepatic dysfunction may cause sarcopenia, and alcohol can also cause sarcopenia directly or by its metabolites [14]. Ongoing alcohol use after enrollment might be directly associated with the development of cirrhotic complications. The other lifestyle factors to consider are nutrition and physical activity. Malnutrition is frequently observed in patients with cirrhosis by multifactorial etiologies, such as inadequate dietary intake, ascites, gastroparesis, hormonal change, and altered metabolism [15]. In addition, reduced exercise capacity and impaired physical performance are commonly observed in patients with cirrhosis [16]. Physical inactivity might lead to sarcopenia in cirrhotic patients, as physical activity and exercise are anabolic stimuli that can improve the muscle protein balance, reducing the protein loss and increasing the muscle mass and contractile function [16]. Therefore, it is necessary to consider factors such as alcohol abuse, diets, and physical activity of enrolled patients during the follow-up period.
Thirdly, the quality of muscle is important, as well as muscle mass. Muscle quality is associated with myosteatosis, which refers to ectopic fat infiltration in muscle. Myosteatosis is defined by lower mean skeletal muscle radiodensity on computed tomography (CT), and it is common in cirrhotic patients with prevalence of 16–82%. Myosteatosis is independently associated with mortality and complications in patients with cirrhosis [17]. Since CT was used for muscle mass evaluation, assessing myosteatosis would also be possible in the patients enrolled in the study by Kim et al. [11]. Moreover, further analysis of myosteatosis would provide additional prognostic information in cirrhotic patients.
In conclusion, we genuinely appreciate the valuable work of Kim et al. [11], which demonstrated that the change in muscle mass is an independent prognostic factor in predicting the development of cirrhotic complications. However, consideration of other issues that can affect muscle mass and quality in cirrhotic patients will be more helpful in identifying patients with a poor prognosis.


Authors’ contribution
Concept of the work: D.S.S. and J.M.Y.; drafting article: D.S.S. and U.I.C.; critical revision of the article: J.M.Y
Conflicts of Interest
The authors have no conflicts to disclose.


computed tomography


1. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017;36:49-64.
crossref pmid
2. DiMartini A, Cruz RJ Jr, Dew MA, Myaskovsky L, Goodpaster B, Fox K, et al. Muscle mass predicts outcomes following liver transplantation. Liver Transpl 2013;19:1172-1180.
crossref pmid pmc pdf
3. Tantai X, Liu Y, Yeo YH, Praktiknjo M, Mauro E, Hamaguchi Y, et al. Effect of sarcopenia on survival in patients with cirrhosis: a meta-analysis. J Hepatol 2022;76:588-599.
crossref pmid
4. Han JW, Kim DI, Nam HC, Chang UI, Yang JM, Song DS. Association between serum tumor necrosis factor-α and sarcopenia in liver cirrhosis. Clin Mol Hepatol 2022;28:219-231.
crossref pmid pdf
5. Choi K, Jang HY, Ahn JM, Hwang SH, Chung JW, Choi YS, et al. The association of the serum levels of myostatin, follistatin, and interleukin-6 with sarcopenia, and their impacts on survival in patients with hepatocellular carcinoma. Clin Mol Hepatol 2020;26:492-505.
crossref pmid pmc pdf
6. Montano-Loza AJ, Meza-Junco J, Prado CMM, Lieffers JR, Baracos VE, Bain VG, et al. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol 2012;10:166-173.
crossref pmid
7. Gu DH, Kim MY, Seo YS, Kim SG, Lee HA, Kim TH, et al. Clinical usefulness of psoas muscle thickness for the diagnosis of sarcopenia in patients with liver cirrhosis. Clin Mol Hepatol 2018;24:319-330.
crossref pmid pmc pdf
8. Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, et al. Malnutrition, frailty, and sarcopenia in patients with cirrhosis: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2021;74:1611-1644.
crossref pmid pdf
9. European Association for the Study of the Liver (EASL). EASL clinical practice guidelines on nutrition in chronic liver disease. J Hepatol 2019;70:172-193.
crossref pmid
10. Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, et al. ESPEN practical guideline: clinical nutrition in liver disease. Clin Nutr 2020;39:3533-3562.
crossref pmid
11. Kim TH, Jung YK, Yim HJ, Baik JW, Yim SY, Lee YS, et al. Impacts of muscle mass dynamics on prognosis of outpatients with cirrhosis. Clin Mol Hepatol 2022;28:876-889.
crossref pmid pmc pdf
12. Ebadi M, Tandon P, Moctezuma-Velazquez C, Ghosh S, Baracos VE, Mazurak VC, et al. Low subcutaneous adiposity associates with higher mortality in female patients with cirrhosis. J Hepatol 2018;69:608-616.
crossref pmid
13. Sinclair M, Gow PJ, Grossmann M, Angus PW. Review article: sarcopenia in cirrhosis-aetiology, implications and potential therapeutic interventions. Aliment Pharmacol Ther 2016;43:765-777.
crossref pmid
14. Dasarathy J, McCullough AJ, Dasarathy S. Sarcopenia in alcoholic liver disease: clinical and molecular advances. Alcohol Clin Exp Res 2017;41:1419-1431.
crossref pmid pmc pdf
15. Chapman B, Sinclair M, Gow PJ, Testro AG. Malnutrition in cirrhosis: more food for thought. World J Hepatol 2020;12:883-896.
crossref pmid pmc
16. Bellar A, Welch N, Dasarathy S. Exercise and physical activity in cirrhosis: opportunities or perils. J Appl Physiol (1985) 2020;128:1547-1567.
crossref pmid pmc
17. Ebadi M, Tsien C, Bhanji RA, Dunichand-Hoedl AR, Rider E, Motamedrad M, et al. Myosteatosis in cirrhosis: a review of diagnosis, pathophysiological mechanisms and potential interventions. Cells 2022;11:1216.
crossref pmid pmc

Editorial Office
The Korean Association for the Study of the Liver
Room A1210, 53 Mapo-daero(MapoTrapalace, Dowha-dong), Mapo-gu, Seoul, 04158, Korea
TEL: +82-2-703-0051   FAX: +82-2-703-0071    E-mail:
Copyright © The Korean Association for the Study of the Liver.         
TODAY : 92
TOTAL : 1849952
Close layer