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

Background & Aims 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.Methods 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.Results 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 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.