Exercise and physical activity for patients with end-stage liver disease: improving functional status and sarcopenia while on the transplant waiting list
Open accessAbstract
Sarcopenia and physical deconditioning are frequent complications in patients with cirrhosis and end-stage liver disease (ESLD). They are the end result of impaired dietary intake, chronic inflammation, altered macronutrient and micronutrient metabolism, and low physical activity. Frailty is the end result of prolonged sarcopenia and physical deconditioning. It severely affects a patient's functional status and presents in approximately 1 in 5 patients on the liver transplantation waiting list. Sarcopenia, poor physical fitness/cardiopulmonary endurance (CPE), and frailty are all associated with increased mortality in ESLD. Clinical trials addressing the usefulness of exercise in patients with cirrhosis have shown that it improves the metabolic syndrome, sarcopenia, CPE, health-related quality of life, and hepatic venous pressure gradient. Although evidence on the benefits of exercise on clinical outcomes derived from large clinical trials is still missing, based on existing literature from multiple medical subspecialties, we believe that an exercise program coupled to a tailored nutritional intervention benefits both cardiopulmonary and musculoskeletal functions, ultimately translating into improved functional status, sense of well-being, and possibly less complications from portal hypertension. In conclusion, although supervised exercise training is the prevailing approach to manage ESLD patients, such intervention is not sustainable or feasible for most patients. Innovative home-based physical activity interventions may be able to effectively reach a larger number of patients. Liver Transplantation 24 122-139 2018 AASLD.
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RCTs in individuals with MASLD show that exercise improves quality of life, cardiorespiratory fitness, reduces visceral fat, and improves muscle mass and function even in advanced liver disease.
“However, RCTs in individuals with MASLD show that exercise improves quality of life, cardiorespiratory fi tness, reduces visceral fat, and improves muscle mass and function even in advanced liver disease. 320,321”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [320]
The exercise-intervention section reports randomized trials in patients with cirrhosis that found improvements in fitness, muscle measures, and some quality-of-life measures. It does not identify those trial participants as having MASLD; its reported visceral-fat improvement comes from a study in chronic hepatitis C. The Exercise Prescription in ESLD section says severely frail or sarcopenic patients had not been included in clinical trials, so the claim extends the trial findings too far into advanced disease. (LLM, conf=0.90)
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Self-citationKonishi, I., Hiasa, Y., Tokumoto, Y., Abe, M., Furukawa, S., Toshimitsu, K., Matsuura, B., & Onji, M. (2011) · Hepatology Research · doi:10.1111/j.1872-034x.2011.00833.x · Cited by 40 · see citing works
Mu RF ‐1 and p‐ GSK 3β expression in muscle atrophy of cirrhosis
Merli, M., Giusto, M., Molfino, A., Bonetto, A., Rossi, M., Corradini, S. G., Baccino, F. M., Fanelli, F. R., Costelli, P., & Muscaritoli, M. (2013) · Liver International · doi:10.1111/liv.12128 · Cited by 34 · see citing works
Pattullo, V., Duarte‐Rojo, A., Soliman, W. T., Vargas-Vorácková, F., Sockalingam, S., Fantus, I. G., Allard, J. P., & Heathcote, J. (2012) · Liver International · doi:10.1111/liv.12041 · Cited by 31 · see citing works
Self-citation
Flagged first, then by citations
Research works printed but not linked: 3
- Carey EJ, Lai JC, Wang CW, Dasarathy S, Lobach I, Montano-Loza AJ, Dunn MA; for Fitness, Life Enhancement, and Exercise in Liver Transplantation Consortium. A multicen- ter study to define sarcopenia in patients with end-stage liver dis- ease. Liver Transpl 2017;23:625-633.
- ATS Committee on Proficiency Standards for Clinical Pulmo- nary Function Laboratories. ATS statement. Am J Respir Crit Care Med 2002;166:111-117.
- Merli M, Giusto M, Molfino A, Bonetto A, Rossi M, Ginanni Corradini S, et al. MuRF-1 and p-GSK3b expression in muscle atrophy of cirrhosis. Liver Int 2013;33:714-721.
Cited by
Sorted by citations
Tacke, F., Horn, P., Wai-Sun Wong, V., Ratziu, V., Bugianesi, E., Francque, S., Zelber-Sagi, S., Valenti, L., Roden, M., Schick, F., et al. (2024) · Journal of Hepatology · doi:10.1016/j.jhep.2024.04.031 · Cited by 2,210 · see citing works
Sarcopenic Obesity in Liver Cirrhosis: Possible Mechanism and Clinical Impact
Nishikawa, H., Enomoto, H., Nishiguchi, S., & Iijima, H. (2021) · International Journal of Molecular Sciences · doi:10.3390/ijms22041917 · Cited by 56 · see citing works
Ndumele, C. E., Rodriguez, F., Dixon, D. L., Khan, S. S., Mukherjee, D., Bajaj, M., Bangalore, S., Bozkurt, B., Breathett, K., Clarke, S. L., et al. (2026) · JACC · doi:10.1016/j.jacc.2026.03.056 · Cited by 90 · see citing works
Authors, & Collaborators: (2022) · Zeitschrift für Gastroenterologie · doi:10.1055/a-1880-2388 · Cited by 30 · see citing works
- Authors
- Duarte‐Rojo, A., Ruiz‐Margáin, A., Montaño‐Loza, A. J., Macías‐Rodríguez, R. U., Ferrando, A., & Kim, W. R.
- Affiliations
- Division of Gastroenterology and Hepatology
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (MX)
- University of Alberta (CA)
- University of Arkansas for Medical Sciences (US)
- Stanford Medicine (US)
- Corresponding author
- Duarte‐Rojo, Andrés
- ORCID
- Venue
- Liver Transplantation
- Published
- 2017-12-21
- Volume
- 24
- Issue
- 1
- Pages
- 122-139
- ISSN
- 1527-6465 (ISSN-L)
- 1527-6473
- OpenAlex
- W2796635101
- Cited by
- 221
- References
- 83
- Citations by year
- 2026: 15 · 2025: 22 · 2024: 24 · 2023: 30 · 2022: 19 · 2021: 37 · 2020: 26 · 2019: 26 · 2018: 21
- FWCI
- 12.32
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Liver Transplantation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Defense
- Gilead Sciences
- Consejo Nacional de Ciencia y Tecnología
- National Institutes of Health
- Topics
- Health Sciences › Medicine › Hepatology › Liver Disease and Transplantation
- Health Sciences › Medicine › Physiology › Nutrition and Health in Aging
- Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
- Keywords
- exercise training, physical activity, end-stage liver disease, liver cirrhosis, sarcopenia, frailty, functional status, liver transplant waiting list, cardiorespiratory fitness, dietary intervention, home-based exercise, portal hypertension, chronic inflammation
- MeSH terms
- Exercise Therapy, Humans, Liver, Liver Cirrhosis, Nutritional Status, Physical Fitness, Quality of Life, Testosterone, Time Factors, Waiting Lists, Exercise, Liver Transplantation, Malnutrition, Anabolic Agents, Sarcopenia, End Stage Liver Disease
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