Body composition in Liver Cirrhosis and after Transjugular Intrahepatic Portosystemic Shunt: prognostic impact and clinical assessment

Malnutrition is highly prevalent in patients with liver cirrhosis and represents a major determinant of morbidity and mortality. Beyond traditional nutritional assessment, alterations in body composition—particularly sarcopenia, myosteatosis, and adipose tissue redistribution—have emerged as powerful prognostic markers. In patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), nutritional status may both influence post-procedural outcomes and be modified by the intervention itself. However, available evidence is largely retrospective, heterogeneous, and focused mainly on muscle quantity, with limited data on muscle quality and adipose tissue characteristics. The aim of this PhD project was to investigate the prognostic impact of body composition in cirrhosis and to assess longitudinal nutritional changes after TIPS using standardized imaging-based approaches. Methods This research included three complementary studies: a prospective multicenter cohort study evaluating the prognostic role of sarcopenia and myosteatosis in patients with cirrhosis using computed tomography (CT) at the L3 vertebral level; a systematic review of the literature assessing the impact of TIPS on nutritional status and body composition; a prospective multicenter study investigating baseline body composition as a predictor of post-TIPS outcomes and longitudinal changes after the procedure. Muscle mass, muscle attenuation, visceral and subcutaneous adipose tissue, and adipose tissue radiodensity were assessed by CT. Functional performance and frailty were evaluated using validated bedside tests. Clinical outcomes included mortality, hospitalizations, liver decompensation, hepatic encephalopathy (HE), and TIPS failure. Results In the multicenter prospective cohort, muscle alterations were highly prevalent, with myosteatosis representing the most frequent abnormality. Myosteatosis, alone or in combination with sarcopenia, was associated with increased mortality, higher hospitalization rates, impaired muscle function, and greater frailty, independently of liver disease severity. Functional tests correlated more closely with muscle quality than with muscle quantity. The systematic review demonstrated that TIPS placement is generally associated with improvement in nutritional status, particularly increased skeletal muscle mass and a redistribution of adipose tissue characterized by reduced visceral fat and increased subcutaneous fat. In the prospective TIPS cohort, TIPS was associated with a significant increase in skeletal muscle index and an improvement in visceral-to-subcutaneous adipose tissue ratio at follow-up. Lack of muscle mass improvement and adverse adipose tissue characteristics, particularly high subcutaneous adipose tissue radiodensity, were associated with worse post-TIPS outcomes, including ascites recurrence, TIPS failure, and mortality. Conclusions Body composition alterations are highly prevalent in cirrhosis and provide prognostic information beyond traditional clinical scores. Myosteatosis appears to play a central role in disease progression and outcomes, often preceding or accompanying sarcopenia. TIPS placement is associated with favorable changes in muscle mass and adipose tissue distribution, suggesting a potential nutritional benefit in selected patients. However, the absence of muscle gain and persistent adverse adipose tissue features identify patients at higher risk of post-TIPS complications. Comprehensive and integrated assessment of muscle quantity, muscle quality, and adipose tissue should be incorporated into routine clinical evaluation and future prognostic models in cirrhosis and in patients undergoing TIPS.