Sarcopenia as a predictor of post-TIPS outcomes in patients with cirrhosis: a systematic review and meta-analysis

Abstract Background Sarcopenia is present in over half of candidates for transjugular intrahepatic portosystemic shunt (TIPS), yet it remains absent from standard pre-procedural risk stratification. Four prior meta-analyses have reached discrepant conclusions regarding the sarcopenia–mortality association, and the widely repeated association with post-TIPS overt hepatic encephalopathy has never been verified against the primary publications. Methods PubMed, Embase, and Cochrane Library were searched from 1 January 2001 to July 2026. Studies enrolling adults with cirrhosis undergoing TIPS that assessed sarcopenia or body composition via CT or MRI and reported at least one clinical outcome were eligible. Random-effects meta-analysis with restricted maximum likelihood estimation and Hartung-Knapp-Sidik-Jonkman adjustment was performed. Results Thirty-two studies (5,731 patients) were included. Sarcopenia was not significantly associated with post-TIPS overt hepatic encephalopathy (pooled OR 1.76, 95% CI 0.40–7.71, P = 0.24; I² = 75.1%; 3 studies). It was associated with all-cause mortality (pooled HR 2.48, 95% CI 1.66–3.73, P = 0.003, I² = 4.2%; 5 studies), and the mortality prediction interval excluded the null (1.67–3.69). Findings were robust to leave-one-out analysis (HR range 2.26–2.74) and to sensitivity analyses re-including the studies that could not contribute to the primary analysis (pooled HR 2.06–2.29). Myosteatosis was associated with HE and mortality in five individual studies, synthesized qualitatively owing to heterogeneous definitions. Certainty of evidence was rated as MODERATE for HE and LOW for mortality. Conclusion CT-defined sarcopenia was associated with an approximately two-fold higher hazard of all-cause mortality after TIPS (HR 2.48, 95% CI 1.66–3.73). The widely reported association with post-TIPS overt hepatic encephalopathy was not reproduced (OR 1.76, 95% CI 0.40–7.71). Pre-TIPS CT-based body composition assessment is already acquired for procedural planning and may reasonably inform risk stratification. The highest-priority evidence gap is a randomized trial of multimodal prehabilitation in TIPS candidates with sarcopenia. Trial registration PROSPERO CRD420261450360. (registered 14 July 2026)