Physical Frailty and Sarcopenia in Liver Transplantation: How Should They Be Assessed and Addressed?

Physical frailty and sarcopenia are increasingly associated with morbidity and 2-fold mortality in patients with advanced chronic liver disease awaiting liver transplantation (LT). Furthermore, they significantly affect post-LT recovery and patients' ability to return to independent daily living, including employment. The increased prevalence of metabolic risk factors (ie, obesity, diabetes) and the aging population have contributed to the prevalence of physical frailty and the complexity of the multidisciplinary team decision-making that surrounds LT. Therefore, it is essential that physical frailty is identified early in the LT clinical pathway to provide targeted nutritional (1.2-2.0 g/kg protein intake, pancreatic exocrine replacement therapy) and individualized exercise (both aerobic and resistance) interventions in the form of (p)rehabilitation. A variety of clinical tools currently exist to assess the nutritional status of LT recipients, sarcopenia, and physical frailty, including patient questionnaires (ie, Royal Free Hospital Global Assessment, Duke Activity Status Index), easy-to-use "by the bedside" tests (ie, liver frailty index, 6-min walk test), and the more specialist investigations (ie, computer tomography, cardiopulmonary exercise testing). This overview aims to briefly summarize these tools, focusing on their varying ease of use, accessibility, and efficacy in a field that lacks consensus and continuity among LT centers. In addition, the overview highlights the benefits and future challenges of implementing pre- and post-LT rehabilitation programmes.