# Outcomes after TIPS in patients with cirrhosis and sarcopenia: A systematic review and meta-analysis

## TL;DR

This study finds that over half of cirrhosis patients undergoing TIPS have sarcopenia, which often improves after the procedure, but is linked to higher risk of hepatic encephalopathy.

## Contribution

First systematic review and meta-analysis linking sarcopenia with outcomes after TIPS in cirrhosis patients.

## Key findings

- Sarcopenia improves in 57% of cirrhosis patients after TIPS with an average increase in muscle index.
- Sarcopenia is associated with a 3.4-fold higher risk of overt hepatic encephalopathy after TIPS.
- Mortality after TIPS is 18%, but sarcopenia's impact on mortality remains inconclusive.

## Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for complications of portal hypertension (variceal bleeding and refractory ascites). Sarcopenia affects 40–70% of patients with cirrhosis. We evaluated the improvement in sarcopenia after TIPS, the proportion of patients developing overt hepatic encephalopathy (HE) after TIPS and its association with sarcopenia, and the association between sarcopenia and mortality after TIPS.

We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible studies included adults with cirrhosis and sarcopenia assessed by computed tomography (CT), using the skeletal muscle index (L3-SMI), or psoas muscle index (L3-PMI). We searched in eight databases for randomized trials, cohort studies, and case–control, cross-sectional, and case series studies.

Twenty studies were included. The pooled prevalence of sarcopenia in patients with cirrhosis undergoing TIPS was 55.4% (95% CI 41.7–68.2%). Among these, sarcopenia improved in 57% of patients (95% CI 48–65%) after TIPS, with a mean L3-SMI increase of 4.53 cm2/m2 (range: 2.4–6.9 cm2/m2). Sarcopenia was associated with higher odds of overt HE (pooled odds ration [OR] = 3.40, 95% CI 1.85–6.25, p <0.001) and a higher proportion of overt HE (43%, 95% CI 26–61%) than in patients without sarcopenia (12%, 95% CI 7–20%). The proportionate mortality after TIPS was 18.3% (95% CI 14.6–22.8%), across 6–33.6 months of follow-up. The association between sarcopenia and mortality was not significant (HR: 1.95, 95% CI 0.89–4.31, p = 0.078).

In patients with cirrhosis and sarcopenia, TIPS is often followed by an improvement in sarcopenia. Sarcopenia is associated with higher odds of overt HE, whereas the effect of sarcopenia on mortality after TIPS remains uncertain.

Sarcopenia affects over half of patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement. This meta-analysis shows that TIPS is associated with sarcopenia improvement in >50% of patients, suggesting potential benefits beyond portal pressure reduction. Sarcopenia increases the risk of overt hepatic encephalopathy, whereas its effect on post-TIPS mortality remains inconclusive. These findings support routine assessment of sarcopenia to improve risk stratification and clinical decision-making. However, results should be interpreted cautiously because of study heterogeneity and the retrospective nature of the included data. Prospective studies are needed to confirm these findings and refine patient selection for TIPS.

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•Sarcopenia is common in patients with cirrhosis undergoing TIPS (∼55% prevalence).•TIPS improves sarcopenia in 57% of cases.•Pre-existing sarcopenia is associated with a 3-fold increased risk of overt HE after TIPS (pooled OR 3.40, 95% CI 1.85–6.25, p <0.001).•Overall mortality after TIPS is 18% (95% CI 14.6–22.8%).

Sarcopenia is common in patients with cirrhosis undergoing TIPS (∼55% prevalence).

TIPS improves sarcopenia in 57% of cases.

Pre-existing sarcopenia is associated with a 3-fold increased risk of overt HE after TIPS (pooled OR 3.40, 95% CI 1.85–6.25, p <0.001).

Overall mortality after TIPS is 18% (95% CI 14.6–22.8%).