Sarcopenia as a novel biomarker for predicting TIPS outcomes in cirrhotic patients with refractory ascites: Mechanisms linking muscle loss, metabolic dysregulation, and portal hemodynamics.

Background and Aim: Transjugular intrahepatic portosystemic shunt (TIPS) is pivotal for refractory ascites in cirrhosis, yet many patients experience poor outcomes. Sarcopenia, a common muscle-wasting syndrome in cirrhosis, is tied to portal hypertension, but its role in TIPS efficacy remains unclear. This study aimed to assess sarcopenia's impact on post-TIPS ascites resolution, complications, and mechanisms. Materials and Methods: This retrospective multicenter study included 294 cirrhotic patients undergoing TIPS (2016-2021). Sarcopenia was defined by CT-based L3-SMI. Outcomes included ascites resolution (International Club of Ascites criteria), HE, and stent dysfunction. Analyses were adjusted for ΔPPG (PPG reduction), MELD-Na, and NLR as the inflammatory marker. Results: Sarcopenic patients had reduced odds of ascites resolution (OR 0.42, 95% CI 0.28-0.63) and a higher HE risk (HR 2.48, 95% CI 1.72-3.57) versus non-sarcopenic patients. Conclusion: In this study, sarcopenia independently predicted poor TIPS outcomes, including reduced ascites resolution and increased risk of hepatic encephalopathy, through potential hemodynamic and metabolic pathways, supporting its value in personalized management. Screening for sarcopenia may help optimize TIPS candidacy and inform therapies targeting inflammation and ammonia.