Why frailty matters for people with cirrhosis

Posted on: 11th January 2021

We’re delighted to introduce Dr Jennifer Lai MD, MBA, Hepatologist and Associate Professor in Residence at the University of California in San Francisco. She has recently presented at the British Association for the Study of the Liver’s conference on Frailty. 

In this guest blog for the British Liver Trust she talks about cirrhosis and frailty, and the steps that people with cirrhosis can take to prepare their body for surgery.

If you or a loved one has been diagnosed with cirrhosis, it can be a worrying time. Cirrhosis can affect the body in many different ways and prognosis can depend on many different factors, some of which may be out of your control (such as transplant). But one important factor that we can control, to some extent, is frailty.

Frailty is part of the normal ageing process for us all – as we get older our muscle mass and bone density decrease. However, people with cirrhosis are more likely to become frail at an earlier age and at a faster rate than the general population. The main reasons for this are:

  1. Being less able to generate energy and make proteins
    The liver plays an important role in making energy for the body’s organs. If the liver is not functioning well and the body’s organs don’t have enough energy, the body must find energy from elsewhere, such as the muscles. Muscle loss increases frailty.
  2. Fluid retention
    Patients with cirrhosis often have fluid retention in the abdomen, a condition called ascites. This can make you feel full very quickly so you eat less. It can also cause swelling of the intestinal wall which may prevent vital nutrients from being absorbed.
  3. Hepatic encephalopathy
    Some people with cirrhosis have hepatic encephalopathy – sometimes shortened to just HE. This can change your sense of taste, making food less appealing, decrease appetite, and generally make it more difficult to prepare and eat food. It can also make you feel confused so that you forget to eat properly.

All of these factors can also make it more challenging to stay physically active which is critical for keeping the heart, lung, and muscles strong.

Why does it matter?

Research shows that a patient with cirrhosis who is frail will have a much higher risk of death than another patient with the exact same liver disease severity who is physically robust.

If you are frail, you are more likely to need hospital treatment and tend to have worse outcomes after a liver transplant, other operations, or an unexpected illness (such as infection). People who are frail are also more likely to experience serious complications after an unexpected illness.

How is frailty tested?

Your clinician can test how frail you are using a series of tests and assessment. One of the tests is called the ‘liver frailty index’. This measures hand grip strength; the number of times you can do five chair stands (rising from a seated position in a straight-backed chair to a standing position unsupported) and your ability to balance.

This provides a baseline score that you can then work at and try and improve.

How can I improve my frailty?

Fortunately, you can prevent yourself from becoming frail, and existing frailty can be improved or reversed. If you have cirrhosis, this will improve overall health.  It is particularly important if you are about need to have surgery or are on the liver transplantation list. Preparing for this is known as ‘prehabilitation’.

Prehabilitation is the process of ‘enhancing physiological reserve in preparation for an upcoming stressor’. This means making sure that your body has reserves of energy so that it can better cope with an operation.

I like to think of prehabilitation as consisting of three components: eating right, exercising well, and engaging in your care.

Eating right

To find out more about more about eating well if you have liver disease read the British Liver Trust’s Diet and Liver Disease guide.

The particular points that are important to emphasize relating to improving frailty include making sure that you eat enough calories, in particular protein, and making sure you have a high calorie late evening snack.

Exercising well

You may feel that you don’t have any energy or strength. It is important to build this up slowly and tailor the amount of exercise to what you are capable of doing. Try to build up to:

  • some aerobic exercise at least twice a week and totaling 150 minutes each week. Aerobic means doing something that leaves you slightly out of breath but still able to talk.
  • Some sort of resistance training at least twice a week - using both your upper and lower body. Ideally this should include 2-3 sets of 10-15 repetitions.

Engaging in your care

You have already taken the first step by reading this article! Try and build changes into your lifestyle so that they become a habit – part of your regular routine. See taking these steps as just as important as taking any medication that you are given.

Speak to your doctor before making any changes to your diet or exercise plan as they can give you specific advice that is right for you.

You can do this!  Stay strong.