Physical frailty is the most important predictor of early mortality in hospitalized patients with decompensated cirrhosis

Background: Frailty and sarcopenia are associated with mortality in cirrhosis. However, most data come from North American cohorts in the outpatient setting. We aimed to assess the impact of frailty and sarcopenia in a prospective cohort of inpatients with cirrhosis. Methods: All patients with decompensated cirrhosis admitted to our unit between October 2021 and March 2023 were prospectively screened for recruitment. Frailty was assessed using the liver frailty index, while sarcopenia was assessed via skeletal muscle index on CT scans performed during hospitalization, respectively. All patients were followed for transplant-free survival as the primary outcome. Results: We included 127 patients (median age 59 y; 68.5% male; median MELD score: 22; 70% with Child-Pugh C cirrhosis). At inclusion, 48.8% of patients were frail, and 60% were sarcopenic. Compared with robust and non-sarcopenic individuals, those with frailty and sarcopenia required ICU care more frequently during hospitalization. Moreover, frailty was associated with a longer hospital stay (15 [9-27] vs. 6.5 [4-15]; p=0.001). During a median follow-up of 96 days (IQR 37-384), 39.4% patients died. Frailty and sarcopenia were associated with a higher mortality (60% vs. 20% and 58% vs. 38%, respectively; p<0.001 and p<0.013). However, in multivariate analysis, only frailty (HR: 2.218; 95% CI: 1.314-3.743; p=0.003) was an independent predictor of reduced transplant-free survival. Conclusions: Frailty emerges as the strongest, independent predictor of early mortality in cirrhosis patients with acute decompensation. Thus, its assessment via the liver frailty index should be performed to improve risk stratification and clinical management.