Previous Article in Journal
Liver Toxicity Induced by Exposure to Bisphenol Analogs at Environmentally Relevant Levels: Insights from a Literature Review on Multiple Species
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Livers
Volume 5
Issue 2
10.3390/livers5020025
livers-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Systematic Review

From Prehabilitation to Rehabilitation: A Systematic Review of Resistance Training as a Strategy to Combat Sarcopenia in Pre- and Post-Liver Transplant Patients

by
Sooraj Vellatt
and
Jonathan Soldera
*
Post-Graduation Program in Gastroenterology, Department of Acute Medicine and Gastroenterology, University of South Wales, Cardiff CF37 1DL, UK
*
Author to whom correspondence should be addressed.
Livers 2025, 5(2), 25; https://doi.org/10.3390/livers5020025
Submission received: 30 March 2025 / Revised: 26 May 2025 / Accepted: 29 May 2025 / Published: 31 May 2025
Browse Figure
Review Reports Versions Notes

Abstract

:
Background: Sarcopenia, defined as the progressive loss of skeletal muscle mass and strength, is a critical predictor of morbidity and mortality in patients with cirrhosis. In chronic liver disease, sarcopenia exacerbates adverse clinical outcomes and deteriorates quality of life. Physical activity, particularly resistance training, has demonstrated beneficial effects in reversing muscle depletion in various chronic conditions. Aim: This systematic review aimed to evaluate the impact of resistance training on sarcopenia among cirrhotic patients, with a focus on both pre-liver transplant and post-liver transplant populations, to improve clinical outcomes and enhance quality of life. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. PubMed/MEDLINE databases were searched for randomized controlled trials (RCTs) using a standardized search command combining MESH terms and Boolean operators. Studies meeting eligibility criteria and reporting improvements in sarcopenia following resistance training were selected for data extraction. Results: Out of 109 references identified, 12 RCTs were included—10 in pre-transplant and 2 in post-transplant populations. Across studies, resistance training led to measurable improvements in key outcomes: peak VO2 increased by up to 5.3 mL/kg/min, 6 min walk distance improved by 18–97 m, quadriceps muscle thickness increased by up to 1.05 cm, and grip strength gains ranged from 0.4 to 3.8 kg. Postoperative studies reported reductions in fatigue severity scores and length of hospital stay, along with improvements in respiratory pressures and peripheral muscle strength. Conclusions: Resistance training is effective in ameliorating sarcopenia in cirrhotic patients, thereby enhancing pre-transplant status and postoperative quality of life. Clinically, structured exercise programs should be routinely implemented.

1. Introduction

Liver cirrhosis represents the end stage of chronic liver injury caused by diverse etiologies, culminating in hepatocellular necrosis, subsequent fibrosis, and the formation of regenerative nodules within the liver parenchyma. This architectural distortion disrupts intrahepatic blood flow, precipitating portal hypertension and progression from an asymptomatic, compensated stage to a decompensated state characterized by clinical deterioration, hospitalizations, reduced quality of life, and elevated mortality. Notably, the Global Burden of Disease Study (GBD) 2017 reported an increase in decompensated cirrhosis cases from 5.2 million in 1990 to 10.6 million in 2017 [1].
Sarcopenia, defined as the progressive loss of skeletal muscle mass and strength, is a critical comorbidity in chronic illnesses, particularly in liver cirrhosis [2,3,4]. It adversely affects functional capacity, quality of life, and survival, and is associated with increased healthcare costs. Sarcopenia is prevalent in cirrhotic patients—with reported rates of up to 48.1% [5,6]—and also appears in other chronic conditions, such as cardiovascular and pulmonary diseases [7]. According to the European Working Group on Sarcopenia in Older People (EWGSOP) revised guidelines, sarcopenia is a generalized skeletal muscle disorder leading to adverse outcomes such as falls, fractures, physical disability, and mortality [3]. The EWGSOP further categorizes sarcopenia into probable, confirmed, and severe stages based on muscle strength, quantity, and physical performance.
Sarcopenia has been identified as an independent predictor of mortality in both pre- and post-liver transplant populations. In cirrhotic patients awaiting liver transplantation, severe muscle depletion is associated with a higher risk of waitlist mortality and longer hospital stays post-transplantation [5,6,7]. Moreover, sarcopenia remains prevalent after transplantation, impacting long-term outcomes, including survival and complications [3]. Pre-transplant sarcopenia predicted longer postoperative hospitalization, while post-transplant sarcopenia persisted as a significant predictor of mortality. Therefore, the early detection and management of sarcopenia in both the pre- and post-transplant periods are critical to optimizing outcomes in this vulnerable population [5,6,7].
The SARC-F questionnaire—a concise, five-item self-report tool—serves as an initial screening instrument for sarcopenia in both community and clinical settings by evaluating limitations in strength, ambulation, rising from a chair, stair climbing, and fall frequency [8]. Subsequent objective assessments include the measurement of grip strength and the chair stand test, which reliably estimate overall muscle strength [9,10]. EWGSOP2 recommends cut-off points for grip strength (<27 kg for males and <16 kg for females) and chair stand performance (>15 s for five rises) to define low muscle strength [11,12]. Skeletal muscle mass is quantified using imaging modalities such as magnetic resonance imaging (MRI) and computed tomography (CT)—considered gold standards—or via more accessible techniques like dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA) [13,14,15]. Calculating the skeletal muscle index (SMI) from CT images at the third lumbar vertebra further refines muscle mass assessment [16]. Ultrasound has emerged as a viable alternative, offering the simultaneous evaluation of muscle quantity and quality, as proposed by the European Geriatric Medicine Society (EuGMS) [17]. Standard thresholds for low muscle mass, such as appendicular skeletal muscle mass (ASM) cut-offs (<20 kg for men and <15 kg for women) or ASM adjusted for height (<7.0 kg/m2 for men and <5.5 kg/m2 for women), have been established [18,19,20].
Physical performance, an integral component of sarcopenia evaluation, is measured via tests such as the 6 min walk distance (6MWD), gait speed, the Short Physical Performance Battery (SPPB), and the Timed Up and Go (TUG) test [21,22,23,24]. The 6MWD, for instance, not only reflects aerobic capacity but also predicts mortality in liver transplant candidates, with thresholds commonly set below 500 m or 400 m [25]. Additionally, cut-off points for gait speed (≤0.8 m/s), SPPB scores (≤8), TUG duration (≥20 s), and the 400 m walk test (non-completion or ≥6 min) further delineate functional impairment [26,27,28,29,30].
In patients with liver cirrhosis, sarcopenia arises from disturbances in whole-body protein homeostasis caused by nutritional, metabolic, and biochemical abnormalities. Studies indicate a strong association between sarcopenia and poor outcomes in cirrhotic patients, including higher mortality and complications post-liver transplantation [31,32,33]. Mechanistic insights suggest that elevated myostatin expression in skeletal muscle may contribute to the increased mortality observed in sarcopenic post-transplant patients, highlighting the potential benefit of therapeutic strategies targeting myostatin [34]. While the relationship between sarcopenia and liver disease severity (e.g., Child–Pugh and MELD scores) is well established in cirrhosis, such correlations in hepatocellular carcinoma remain controversial [35,36]. Given the prognostic significance of sarcopenia, early detection and management are paramount, with treatment strategies encompassing nutritional, physical, and pharmacological interventions [37].
Exercise interventions, both aerobic and resistance training, are central to the management of sarcopenia in cirrhosis. Aerobic exercises improve cardiorespiratory fitness—as measured by peak VO2 and the 6MWD—while resistance training enhances muscle mass, strength, and overall physical performance [38,39,40]. Supervised, site-based exercise programs generally achieve higher adherence compared to home-based regimens, although both formats demonstrate benefits [41]. Resistance training protocols, often based on guidelines from the American College of Sports Medicine and the American Heart Association, involve structured sessions targeting major muscle groups to induce muscle hypertrophy and strength gains [42]. Caution is warranted, particularly in decompensated cirrhosis, due to the potential risk of exercise-induced portal pressure surges; thus, appropriate safety measures—such as beta-blockade and avoidance of high intra-abdominal pressure activities—are essential [43,44,45,46,47]. Moreover, exercise training may confer additional benefits by reducing portal hypertension, possibly via reductions in systemic inflammation and improvements in endothelial function [48]. Enhanced exercise capacity has been linked to improved outcomes in cirrhosis, although it may be compromised by disease-specific factors including reduced ventilatory capacity and altered skeletal muscle blood flow [49,50,51,52,53].
Sarcopenia significantly impacts the prognosis of cirrhotic patients. Its assessment—via measures of muscle strength, mass, and physical performance—is essential for timely intervention. Tailored exercise programs, combined with nutritional and pharmacological therapies, offer promising avenues to ameliorate sarcopenia and improve clinical outcomes in liver cirrhosis.
This study aims to systematically evaluate the efficacy of resistance training as an intervention to ameliorate sarcopenia in patients with liver cirrhosis. Specifically, the investigation seeks to determine whether structured resistance training programs can significantly enhance skeletal muscle mass, muscle strength, and overall physical performance in this patient population.

2. Materials and Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, were utilized to perform this systematic review, after searching the literature in Pubmed/MEDLINE database [54].
The protocol for this systematic review was registered on PROSPERO under the IDCRD42024554681.

2.1. Search Strategy

A comprehensive literature search was conducted using the PubMed/MEDLINE search engine database by the principal researcher, without any date or language restrictions, to identify relevant studies with the following search commands.
The search strategy included the following terms as commands: (“exercise training” OR “resistance training” OR “force training” OR “muscle training” OR “muscle exercise” OR “aerobic exercise” OR “anaerobic exercise”) AND (“cirrhosis” OR “liver failure” OR “hepatic failure” OR “liver transplantation” OR “end-stage liver disease”).

2.2. Study Selection

Randomized controlled studies dealing with resistance training in sarcopenia in cirrhosis patients, regardless of age, sex, date and year of publication, and published in English were selected. Those patients with diagnosed cirrhosis of the liver, irrespective of the etiology and liver status with sarcopenia, pre- or post-liver transplant and irrespective of gender, were included in the study. Review articles, non-randomized trials, case control studies, studies not written in English, and studies with missing data were excluded. Although our primary focus was on randomized controlled trials, we included one high-quality retrospective cohort study (Al-Judaibi et al.) due to its structured intervention design and comparative analysis of clinically relevant outcomes across well-defined patient groups

2.3. Data Extraction

The systematic search using the PubMed/MEDLINE search engine database was conducted by one reviewer. The relevant studies, based on their titles, were screened and those coming under the purview of our aim were filtered out. Full-text versions or abstracts of selected eligible studies were thoroughly analyzed for their content and methodology.
Using PRISMA 2020 flowchart, a summary of the selected studies was made. Each selected study was thoroughly reviewed for its aim, methodology and results obtained. The data were extracted from these studies. Data extracted from the selected studies included the number of participants in each group, the intervention group, i.e., resistance training and the control group; the methodology of training; the outcomes, both primary and secondary after resistance training; and the results, i.e., the number of participants who achieved the outcomes; and their significance in relation to the improvement in sarcopenia. Listing or transplantation status was only explicitly stated in some studies. Where not specified, inclusion criteria included cirrhotic patients, and listing status could not be confirmed from the original publication.

3. Results

Of the 109 results that were selected by the search strategy relevant to our study, in PubMed/Medline, 17 articles were duplicated. Of the remaining 92 studies, only 66 studies were retrieved. These retrieved studies were scrutinized to satisfy the eligibility criteria. Thus, after scrutiny, 13 studies were marked as eligible, as shown in Figure 1. The data pertaining to the study in question were extracted and reviewed. The results were analyzed and segregated into pre-transplant patients—Table 1—and post-liver transplant patients—Table 2.

3.1. Systematic Review Results

3.1.1. Pre-Liver Transplantation Patients

A series of randomized controlled trials (RCTs) were conducted to investigate the role of exercise interventions—primarily focusing on resistance and aerobic training—in improving the clinical status of patients with cirrhosis awaiting liver transplantation. These studies collectively underscore the potential of structured exercise programs to enhance exercise capacity, muscle mass, and overall quality of life, while also suggesting possible reductions in hospital stays and improvements in long-term outcomes.
Zenith et al. [55] conducted a pilot RCT at the University of Alberta Hospital, enrolling stable patients with Child–Pugh class A or B cirrhosis. Participants randomized into an 8-week supervised aerobic training program (cycling at 60–80% of baseline peak VO2, three times per week) demonstrated a significant increase in peak VO2 by 5.3 mL/kg/min compared to controls. Additionally, improvements were observed in quadriceps muscle thickness, thigh circumference, self-perceived health status via EQ-visual analogue scales, and reduced fatigue scores, with no adverse events reported.
In a similar vein, Kruger et al. [47] evaluated an 8-week home-based exercise training (HET) regimen involving moderate- to high-intensity cycling in a cohort of cirrhotic patients. Although the overall increase in peak VO2 did not reach statistical significance in the entire cohort, a subgroup analysis of adherent participants revealed significant improvements in both peak VO2 and 6 min walk distance (6MWD), with the intervention proving safe and well tolerated [47,56,57].
Wallen et al. [44] explored the feasibility and safety of an 8-week exercise program in patients awaiting liver transplantation. Despite the limited sample size and absence of statistically significant improvements in cardiorespiratory fitness or muscular strength, the study confirmed that even patients with advanced liver disease can safely participate in structured exercise regimens, thereby providing preliminary data to inform larger trials.
Al-Judaibia et al. [58] retrospectively compared outcomes between patients who underwent liver transplantation before and after the implementation of a comprehensive exercise training program. Their findings suggested that the exercise group experienced trends towards lower 90-day readmission rates and shorter hospital stays, despite having a higher prevalence of comorbid conditions such as diabetes mellitus and coronary artery disease.
Aamann et al. [59] conducted an RCT among patients with compensated cirrhosis, evaluating the effects of 12 weeks of supervised progressive resistance training. The intervention group showed significant gains in maximal muscle strength, quadriceps cross-sectional area as measured by magnetic resonance imaging, whole-body lean mass, and improvements in the 6MWD and mental health parameters compared with controls who maintained their usual activity levels.
Nóbrega et al. [60] investigated the application of resistance training combined with blood flow restriction (BFR-RT) in cirrhotic patients. This innovative approach aimed to enhance muscle strength and mass, as well as to improve functional performance and quality of life, although the study called for further research to validate these preliminary findings.
Sirisunhirun et al. [61] evaluated a 12-week home-based exercise training (HoBET) program in patients with compensated cirrhosis. While the primary outcome—changes in the 6MWD—did not differ significantly between the intervention and control groups, the study provided valuable pilot data regarding the feasibility and safety of home-based programs, recommending the use of more sensitive measures such as cardiopulmonary exercise testing and computed tomography for future trials.
Lai et al. [41] introduced the STRIVE program—a 12-week, home-based structured strength training intervention developed using the Information–Motivation–Behavioral Skills (IMB) model. Despite low adherence to the strength training component, participants in the STRIVE arm exhibited notable improvements in quality of life scores, although changes in physical frailty were modest compared to standard care [41,62].
Finally, Aamann et al. [63] extended the investigation by examining the long-term impact of a 12-week resistance training program on hospitalization and mortality over a 3-year follow-up period. Their results indicated that the training group had a significantly lower risk of first hospitalization and reduced all-cause mortality compared to controls, suggesting that resistance training may exert enduring beneficial effects on clinical outcomes in cirrhotic patients.
These studies provide robust evidence that structured exercise interventions, particularly those incorporating resistance training, are both safe and effective in enhancing physical capacity and quality of life in cirrhotic patients awaiting liver transplantation. However, variability in adherence and methodological differences among trials highlight the need for larger, multicenter studies to confirm these promising findings and to elucidate the underlying mechanisms driving these clinical improvements.

3.1.2. Post-Liver Transplantation Patients

Two randomized controlled trials (RCTs) evaluated the effects of exercise in post-liver transplant patients. 64. Moya-Nájera et al. (2017) demonstrated significant improvements (p < 0.05) in aerobic capacity, hip extension, elbow flexion, maximal strength, and health-related quality of life (HRQoL) in the intervention group (IG) compared to the control group (CG), with no significant changes in body composition or liver function tests. Adherence to the program was 94% [64].
Similarly, Ergene et al. (2022) reported superior physical performance outcomes in the exercise group (EG) compared to the CG (p = 0.001 and p = 0.048, respectively), with significant enhancements in fatigue perception (p = 0.001 vs. p = 0.006). The treatment group (TG) exhibited improvements in exercise capacity, peripheral muscle strength, and respiratory pressures (p = 0.001; p = 0.047), while the CG remained unchanged. Notably, a clinically meaningful increase of 0.9 kg in peripheral muscle strength and >37.8 m in the six-minute walk distance (6MWD) was observed [65].
These findings underscore the substantial benefits of structured exercise training in both liver transplant candidates and recipients, highlighting its role in optimizing functional recovery and overall physical performance.

3.1.3. Risk of Bias Assessment

Risk of bias was assessed for all included randomized controlled trials using the Cochrane Risk of Bias tool (RoB 2)—Table 3. Studies were evaluated across key domains, including the randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selection of the reported results. Most trials demonstrated a low or moderate risk of bias, although a few had unclear reporting in domains such as allocation concealment and outcome assessor blinding. The retrospective cohort study by Al-Judaibi et al. was not assessed using RoB 2 but was acknowledged as a high-risk design due to its observational nature.
Table 1. Summary of pre-liver transplantation studies.
Table 1. Summary of pre-liver transplantation studies.
Author (Year)Number of Patients (IG/CG)DesignInterventionOutcomes MeasuredSafety OutcomesOutcome Data (IG/CG)
Al-Judaibi et al. (2019) [58]258/200Retrospective cohortComprehensive in/outpatient program, 5×/week; physiotherapy, home, hospital, and online support90-day readmission, LOS, post-op surgical/vascular/medical complicationsSurgical, vascular, infectious complications (UTI, pneumonia, C. diff)Readmission: 45 vs. 41; MSK rehab: 4 vs. 1; LOS: 14 vs. 17 d; surgical: 72 vs. 55; vascular: 10 vs. 12; medical: 63 vs. 35
Aamann et al. (2020) [63]20/19RCTSupervised resistance training, 3×/week, 12 weeksMuscle strength, CSA (MRI), lean mass, 6MWDNo safety events reportedStrength: +11 vs. 0 N·m; CSA: +4.4 vs. 0 cm2; lean mass: +1.7 vs. 0 kg; 6MWD: +18.8 vs. 0 m
Zenith et al. (2014) [55]9/10RCTCycle ergometer, 3×/week, 8 weeks, 60–80% VO2 peakPeak VO2, quad circumference, 6MWD, QoLNo variceal bleeding or hepatic decompensationVO2: +5.3 vs. 0 mL/kg/min; circumference: +1.05 vs. 0 cm; 6MWD: +23.5 vs. 0 m; QoL: +20.4 vs. 0 pts
Kruger et al. (2018) [47]20/20RCTModerate-high intensity cycling, 3×/week, 8 weeksPeak VO2, 6MWD, thigh circumference and muscle thicknessNo MSK injuries, variceal bleeding, or liver decompensationVO2: +2.9 vs. 0.2 mL/kg/min; 6MWD: +30.4 vs. −20.4 m; thigh: +1.8 vs. 0.6 cm; thickness: +0.6 vs. 0.06 cm/m2
Wallen et al. (2019) [44]8/9RCTHospital- and home-based aerobic + resistance, 8 weeksVT, VO2 peak, 6MWD, grip strength, global strengthNo adverse events, encephalopathy, or MSK injuriesVT: +1.2 mL/kg/min; VO2: +1.5; 6MWD: +16 m; Grip: +0.4 kg; global strength: −51.1 N (no CG data)
Sirisunhirun et al. (2022) [61]20/20RCTHome-based moderate aerobic/isotonic training, 4×/week, 12 weeks6MWD, QoL, thigh mass, HVPGNo variceal bleeding or new ascites6MWD: +18.8 m; compression index: +0.08 cm/m2; HVPG: −0.04 kPa; QoL: +5.6 pts
Lai et al. (2021) [41]58/25RCTSTRIVE strength training + coaching, 12 weeksLiver Frailty Index, CLDQ QoL, steps/dayNo adverse events; liver function unchangedLFI: −3.8 vs. −3.7 pts; QoL: +0.4 vs. 0.0 pts; steps/day: +4451 vs. +3569
Aamann et al. (2023) [59]20/19RCTSupervised resistance training, followed 3 yearsHospitalization, mortality, CirCom score, 6MWDNo major adverse events reportedAdmission: 9 vs. 15; mortality: 1 vs. 5; CirCom ≥1: 6 vs. 4; 6MWD: +32.4 vs. +11.3 m
Rossi et al. (2022) [19]13/12RCTSupervised face-to-face vs. non-supervised home-based aerobic training, 2×/week, 12 weeksFatigue, respiratory/pulmonary strength, 6MWD, SF-36 QoLNo adverse events notedFatigue: −1.86 vs. +0.1; PiMax: −23 vs. −2.5; torque: +28.5 vs. −0.65 N·m; 6MWD: +97.8 vs. +11.7 m; QoL: functional +19.7 vs. −1.17 pts
Abbreviations: RCT: randomized controlled trial; IG/CG: intervention group/control group; 6MWD: 6-min walk distance; VO2/Peak VO2: maximal oxygen consumption; CSA: cross-sectional area (of muscle); QoL: quality of life; HVPG: hepatic venous pressure gradient; CLDQ: Chronic Liver Disease Questionnaire; VT: ventilatory threshold; ETP: exercise training program; LOS: length of stay.
Table 2. Summary of post-liver transplantation studies.
Table 2. Summary of post-liver transplantation studies.
Author (Year)Number of Patients (IG/CG)DesignInterventionOutcomes MeasuredSafety OutcomesOutcome Data (IG/CG)
Moya-Nájera et al. (2017) [64]21/20RCTSupervised resistance and aerobic training, 3×/week, 12 weeksAerobic capacity, muscle strength, QoL, liver enzymes, body compositionNo adverse events reportedVO2 ↑; hip/elbow strength ↑; SF-36 ↑; no change in LFTs/body composition
Ergene et al. (2022) [65]25/25RCTRespiratory muscle training + physical rehab, 8 weeks6MWD, respiratory pressures (MIP/MEP), deltoid strength, fatigue, QoLNo adverse events reported6MWD: +97 m; fatigue score ↓ 3.7 pts; MIP/MEP ↑; QoL ↑
RCT: randomized controlled trial; IG/CG: intervention group/control group; 6MWD: 6-minute walk distance; MIP/MEP: maximal inspiratory pressure/maximal expiratory pressure; HRQOL: health-related quality of life; VO2: maximal oxygen consumption (VO2 max); SF-36: 36-item short-form survey (QoL measure).
Table 3. Risk of bias assessment (RoB 2).
Table 3. Risk of bias assessment (RoB 2).
StudyRandomization ProcessDeviations from Intended InterventionsMissing Outcome DataMeasurement of OutcomeSelection of Reported ResultOverall Risk of Bias
Aamann et al. (2020) [63]LowLowLowLowLowLow
Zenith et al. (2014) [55]Some concernsLowLowSome concernsLowSome concerns
Kruger et al. (2018) [47]LowLowLowLowLowLow
Wallen et al. (2019) [44]Some concernsLowLowLowSome concernsSome concerns
Sirisunhirun et al. (2022) [61]LowLowLowLowLowLow
Lai et al. (2021) [41]LowLowSome concernsLowLowLow
Aamann et al. (2023) [59]LowLowLowLowLowLow
Rossi et al. (2022) [19]LowLowLowLowLowLow
Moya-Nájera et al. (2017) [64]LowLowLowLowLowLow
Ergene et al. (2022) [65]LowLowLowLowLowLow
Al-Judaibi et al. (2019) [58]Not applicableNot applicableHighHighHighHigh (observational)

4. Discussion

This review encompassed 12 randomized controlled trials (RCTs) evaluating exercise interventions in cirrhotic patients, with 10 studies addressing the pre-transplant population and 2 focusing on post-transplant recipients. In the post-transplant studies, Moya-Najera et al. [64] reported that the intervention group exhibited significant improvements (p < 0.05) in aerobic capacity, hip extension, elbow flexion, overall maximal strength, and health-related quality of life (HRQOL) compared to controls, with no notable changes in body composition or liver function tests. Similarly, Ergene et al. [65] demonstrated that the exercise group achieved superior enhancements in physical performance—evidenced by improved exercise capacity, peripheral muscle strength, and respiratory pressures—with clinically significant increases in deltoid strength and a greater six-minute walk distance (6MWD).
In both pre- and post-transplant cohorts, exercise training consistently yielded positive outcomes. Supervised exercise programs, in particular, showed higher adherence rates, correlating with superior improvements in primary and secondary endpoints. Importantly, no adverse events were reported across trials, underscoring the safety of these interventions even in patients with advanced liver disease.
While the included RCTs consistently demonstrated improvements in functional outcomes such as muscle strength, aerobic capacity, and quality of life, none of the trials specifically assessed pre- or post-transplant survival as a primary endpoint. The exception was a 2023 study which reported a reduction in hospital admissions and all-cause mortality over a 3-year follow-up in pre-transplant cirrhotic patients undergoing resistance training. However, this study did not focus exclusively on post-transplant survival outcomes [59]. The two post-transplant RCTs—by Moya-Nájera et al. and Ergene et al.—focused on functional improvements but did not report survival data. This highlights a gap in the current evidence base, and future trials should aim to investigate the direct impact of pre- and post-transplant exercise interventions on survival and long-term clinical outcomes [64,65].
Assessing physical performance is critical in evaluating sarcopenia. Reliable tests—including the gait speed test [22], Short Physical Performance Battery (SPPB) [23], and Timed Up and Go (TUG) test [24]—offer valuable insights into whole-body function, balance, and neuromuscular coordination. Established cut-off values, such as a gait speed ≤0.8 m/s [3,28] and SPPB scores ≤8 [23], serve as predictors of adverse outcomes, including disability, falls, and increased mortality [26,27,30,66].
Sarcopenia, a common comorbidity in decompensated cirrhosis, results from disturbances in protein homeostasis due to nutritional, metabolic, and biochemical imbalances. Studies have identified factors—such as male gender, ascites, and higher Child–Pugh and MELD scores—as significant predictors of sarcopenia [31,32,33]. Elevated myostatin expression may further contribute to increased post-transplant mortality [34], although its association in hepatocellular carcinoma remains controversial [35,36]. Early identification and multidisciplinary management, integrating nutritional, physical, and pharmacological strategies, are therefore essential [37].
Exercise interventions—particularly those combining aerobic and resistance training—improve muscle mass, strength, and overall quality of life [40]. While hospital-based programs benefit from superior adherence due to regular supervision and specialized equipment, home-based programs provide practical advantages despite lower adherence rates [41]. Resistance training protocols, aligned with guidelines from the American College of Sports Medicine and the American Heart Association [42], promote muscle hypertrophy and strength gains. However, caution is warranted in decompensated cirrhosis to mitigate exercise-induced portal pressure elevations, which can be managed through appropriate safety measures [43,44,45,46,47]. Long-term benefits, such as reductions in portal hypertension [48] and improved quality of life via exercise-induced “exerkines” [67], further substantiate the role of structured exercise in managing cirrhosis. Finally, diminished exercise capacity in cirrhosis—attributable to factors like reduced ventilatory capacity, impaired VO2max, and altered regional blood flow—necessitates targeted interventions [49,50,51,52,53].
The resistance training program in the reviewed studies was developed according to the guidelines of the American College of Sports Medicine and the American Heart Association, specifically targeting improvements in muscle strength and mass among older adults [42]. In these programs, participants engaged in hour-long sessions, conducted on three nonconsecutive days per week over a 12-week period, totaling 36 sessions in small groups under the supervision of trained instructors and physicians. Each session commenced with a five-minute warm-up on a rowing machine, followed by a series of seven exercises encompassing major muscle groups. For the lower extremities, exercises such as leg press, leg extension, and hamstring curl were performed in three sets, while upper body and core exercises—lateral pull-down, chest press, hyperextension, and abdominal exercises—were similarly structured. Progression was achieved by reducing repetitions from 15 initially to 8 by week 11, with simultaneous increments in resistance, ensuring that the final repetitions remained challenging for untrained individuals [42].
Resistance training appears safe in cirrhotic patients, including those with portal hypertension, when conducted under appropriate supervision and safety protocols. No major adverse events such as variceal bleeding were reported in the included studies, using measures such as the maintenance of beta-blockade and the avoidance of exercises known to acutely increase intra-abdominal pressure, such as certain abdominal crunches [43,44,45,46,47].
In addition to acute safety, resistance training demonstrates long-term benefits. For instance, an open-label pilot RCT reported that a 14-week program combining aerobic and resistance exercises led to a reduction in portal venous pressure by 2.5 mm Hg, likely mediated by decreased systemic inflammation, improved endothelial function, and reduced intrahepatic resistance [48]. Moreover, exercise interventions have been shown to enhance overall quality of life by mitigating fatigue, depression, and anxiety. This improvement may be partially attributed to the release of “exerkines”, biochemical mediators produced in response to exercise that exert beneficial effects on brain function and mood [67].
Comparatively, resistance training appears to exert a more pronounced effect on sarcopenia than aerobic training, as evidenced by significant gains in skeletal muscle strength and mass, although improvements in aerobic fitness—as measured by tests such as the 6 min walk test—are less evident [49]. The diminished exercise capacity observed in cirrhosis is multifactorial, involving reduced ventilatory capacity [49,50], decreased inspiratory pressure [51], impaired maximal oxygen uptake (VO2max), and diminished oxygen delivery due to anemia or altered regional blood flow. Notably, while resting skeletal muscle blood flow remains unchanged, it increases in response to exercise, suggesting that well-structured training programs can overcome some of these limitations [52,53]. Additionally, comorbidities and cardiopulmonary dysfunction may further contribute to reduced exercise capacity.
Moreover, several recent randomized trials have reinforced the beneficial impact of resistance training on clinical outcomes in cirrhotic patients. One study demonstrated that a 24-week resistance training program significantly reduced fatigue and enhanced quality of life in compensated cirrhotic patients, with marked improvements in the Chronic Liver Disease Questionnaire and SF-36 domains compared to controls [68]. In another trial, resistance training was shown to produce significant increases in isokinetic muscle strength and quadriceps muscle thickness over 12 and 24 weeks, underscoring its efficacy in augmenting muscle mass and strength [69]. Additionally, a clinical trial investigating an aerobic rehabilitation program in cirrhotic patients reported improvements in functional capacity—as evidenced by increased six-minute walk distance and reduced fatigue—even though changes in muscle strength were less pronounced [70]. Collectively, these studies suggest that tailored exercise regimens, particularly those incorporating resistance training, can substantially mitigate the deleterious effects of sarcopenia in cirrhotic patients, thereby improving exercise capacity and overall health outcomes without incurring significant adverse events.
Overall, these findings indicate that structured resistance training not only enhances muscle strength and mass but also improves physical endurance and quality of life in cirrhotic patients, with sustained benefits and minimal adverse events when appropriate precautions are taken. These results align with recent evidence emphasizing the importance of maintaining muscle health to potentially mitigate complications in cirrhosis, such as minimal hepatic encephalopathy [71].

5. Conclusions

Resistance training exercise programs improve the aerobic and physical capacity of patients with cirrhosis. They improve sarcopenic status, thereby improving quality of life. Those patients who are waiting for liver transplant will benefit from a reduced morbidity risk, shorter hospital stays and thus a faster recovery post-liver transplant. This systematic review opens up a new management strategy of resistance muscular training to be implemented on a routine basis in patients with cirrhosis in order to improve clinical outcomes and quality of life.

Author Contributions

Conceptualization, S.V. and J.S.; methodology, J.S.; investigation, S.V.; writing—original draft preparation, J.S.; writing—review and editing, J.S.; supervision, J.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Acknowledgments

We extend our appreciation to the Faculty of Life Sciences and Education at the University of South Wales in association with Learna Ltd. for their Gastroenterology MSc program and their invaluable support of our work. We sincerely acknowledge the efforts of the University of South Wales and commend them for their commitment to providing life-long learning opportunities and advanced life skills to healthcare professionals.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Huang, D.Q.; Terrault, N.A.; Tacke, F.; Gluud, L.L.; Arrese, M.; Bugianesi, E.; Loomba, R. Global epidemiology of cirrhosis-aetiology, trends and predictions. Nat. Rev. Gastroenterol. Hepatol. 2023, 20, 388–398. [Google Scholar] [CrossRef] [PubMed]
  2. Morley, J.E.; Baumgartner, R.N.; Roubenoff, R.; Mayer, J.; Nair, K.S. Sarcopenia. J. Lab. Clin. Med. 2001, 137, 231–243. [Google Scholar] [CrossRef] [PubMed]
  3. Cruz-Jentoft, A.J.; Baeyens, J.P.; Bauer, J.M.; Boirie, Y.; Cederholm, T.; Landi, F.; Martin, F.C.; Michel, J.P.; Rolland, Y.; Schneider, S.M.; et al. European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010, 39, 412–423. [Google Scholar] [CrossRef] [PubMed]
  4. Keller, K.; Engelhardt, M. Strength and muscle mass loss with aging process. Age and strength loss. Muscles Ligaments Tendons J. 2013, 3, 346–350. [Google Scholar] [CrossRef] [PubMed]
  5. Kim, G.; Kang, S.H.; Kim, M.Y.; Baik, S.K. Prognostic value of sarcopenia in patients with liver cirrhosis: A systematic review and meta-analysis. PLoS ONE 2017, 12, e0186990. [Google Scholar] [CrossRef] [PubMed]
  6. Soldera, J. Exercise and Sarcopenia in Cirrhosis. Gastroenterol. Med. Res. 2018, 2–3. [Google Scholar] [CrossRef]
  7. Shafiee, G.; Keshtkar, A.; Soltani, A.; Ahadi, Z.; Larijani, B.; Heshmat, R. Prevalence of sarcopenia in the world: A systematic review and meta- analysis of general population studies. J. Diabetes Metab. Disord. 2017, 16, 21. [Google Scholar] [CrossRef] [PubMed]
  8. Bahat, G.; Yilmaz, O.; Kılıç, C.; Oren, M.M.; Karan, M.A. Performance of SARC-F in Regard to Sarcopenia Definitions, Muscle Mass and Functional Measures. J. Nutr. Health Aging 2018, 22, 898–903. [Google Scholar] [CrossRef] [PubMed]
  9. Roberts, H.C.; Denison, H.J.; Martin, H.J.; Patel, H.P.; Syddall, H.; Cooper, C.; Sayer, A.A. A review of the measurement of grip strength in clinical and epidemiological studies: Towards a standardised approach. Age Ageing 2011, 40, 423–429. [Google Scholar] [CrossRef] [PubMed]
  10. Beaudart, C.; McCloskey, E.; Bruyère, O.; Cesari, M.; Rolland, Y.; Rizzoli, R.; Araujo de Carvalho, I.; Amuthavalli Thiyagarajan, J.; Bautmans, I.; Bertière, M.C.; et al. Sarcopenia in daily practice: Assessment and management. BMC Geriatr. 2016, 16, 170. [Google Scholar] [CrossRef] [PubMed]
  11. Dodds, R.M.; Syddall, H.E.; Cooper, R.; Benzeval, M.; Deary, I.J.; Dennison, E.M.; Der, G.; Gale, C.R.; Inskip, H.M.; Jagger, C.; et al. Grip strength across the life course: Normative data from twelve British studies. PLoS ONE 2014, 9, e113637. [Google Scholar] [CrossRef] [PubMed]
  12. Cesari, M.; Kritchevsky, S.B.; Newman, A.B.; Simonsick, E.M.; Harris, T.B.; Penninx, B.W.; Brach, J.S.; Tylavsky, F.A.; Satterfield, S.; Bauer, D.C.; et al. Health, Aging and Body Composition Study. Added value of physical performance measures in predicting adverse health-related events: Results from the Health, Aging And Body Composition Study. J. Am. Geriatr. Soc. 2009, 57, 251–259. [Google Scholar] [CrossRef] [PubMed]
  13. Treviño-Aguirre, E.; López-Teros, T.; Gutiérrez-Robledo, L.; Vandewoude, M.; Pérez-Zepeda, M. Availability and use of dual energy X-ray absorptiometry (DXA) and bio-impedance analysis (BIA) for the evaluation of sarcopenia by Belgian and Latin American geriatricians. J. Cachexia Sarcopenia Muscle 2014, 5, 79–81. [Google Scholar] [CrossRef] [PubMed]
  14. Gonzalez, M.C.; Heymsfield, S.B. Bioelectrical impedance analysis for diagnosing sarcopenia and cachexia: What are we really estimating? J. Cachexia Sarcopenia Muscle 2017, 8, 187–189. [Google Scholar] [CrossRef] [PubMed]
  15. Kyle, U.G.; Genton, L.; Hans, D.; Pichard, C. Validation of a bioelectrical impedance analysis equation to predict appendicular skeletal muscle mass (ASMM). Clin. Nutr. 2003, 22, 537–543. [Google Scholar] [CrossRef] [PubMed]
  16. Heymsfield, S.B.; Gonzalez, M.C.; Lu, J.; Jia, G.; Zheng, J. Skeletal muscle mass and quality: Evolution of modern measurement concepts in the context of sarcopenia. Proc. Nutr. Soc. 2015, 74, 355–366. [Google Scholar] [CrossRef] [PubMed]
  17. Perkisas, S.; Baudry, S.; Bauer, J.; Beckwée, D.; De Cock, A.M.; Hobbelen, H.; Jager-Wittenaar, H.; Kasiukiewicz, A.; Landi, F.; Marco, E.; et al. Application of ultrasound for muscle assessment in sarcopenia: Towards standardized measurements. Eur. Geriatr. Med. 2018, 9, 739–757. [Google Scholar] [CrossRef] [PubMed]
  18. Schweitzer, L.; Geisler, C.; Pourhassan, M.; Braun, W.; Glüer, C.C.; Bosy-Westphal, A.; Müller, M.J. What is the best reference site for a single MRI slice to assess whole-body skeletal muscle and adipose tissue volumes in healthy adults? Am. J. Clin. Nutr. 2015, 102, 58–65. [Google Scholar] [CrossRef] [PubMed]
  19. Rossi, D.; D’Avila, A.F.; Galant, L.H.; Marroni, C.A. Exercise in the Physical Rehabilitation of Cirrotics: A Randomized Pilot Study. Arq. Gastroenterol. 2022, 59, 408–413. [Google Scholar] [CrossRef] [PubMed]
  20. Gould, H.; Brennan, S.L.; Kotowicz, M.A.; Nicholson, G.C.; Pasco, J.A. Total and appendicular lean mass reference ranges for Australian men and women: The Geelong osteoporosis study. Calcif. Tissue Int. 2014, 94, 363–372. [Google Scholar] [CrossRef] [PubMed]
  21. Holland, A.E.; Spruit, M.A.; Troosters, T.; Puhan, M.A.; Pepin, V.; Saey, D.; McCormack, M.C.; Carlin, B.W.; Sciurba, F.C.; Pitta, F.; et al. An official European Respiratory Society/American Thoracic Society technical standard: Field walking tests in chronic respiratory disease. Eur. Respir. J. 2014, 44, 1428–1446. [Google Scholar] [CrossRef] [PubMed]
  22. Bruyère, O.; Beaudart, C.; Reginster, J.; Buckinx, F.; Schoene, D.; Hirani, V.; Cooper, C.; Kanis, J.; Rizzoli, R.; Mccloskey, E.; et al. Assessment of muscle mass, muscle strength and physical performance in clinical practice: An international survey. Eur. Geriatr. Med. 2016, 7, 243–246. [Google Scholar] [CrossRef]
  23. Pavasini, R.; Guralnik, J.; Brown, J.C.; di Bari, M.; Cesari, M.; Landi, F.; Vaes, B.; Legrand, D.; Verghese, J.; Wang, C.; et al. Short Physical Performance Battery and all-cause mortality: Systematic review and meta-analysis. BMC Med. 2016, 14, 215. [Google Scholar] [CrossRef] [PubMed]
  24. Podsiadlo, D.; Richardson, S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J. Am. Geriatr. Soc. 1991, 39, 142–148. [Google Scholar] [CrossRef] [PubMed]
  25. Faustini Pereira, J.L.; Galant, L.H.; Rossi, D.; Telles da Rosa, L.H.; Garcia, E.; de Mello Brandão, A.B.; Marroni, C.A. Functional Capacity, Respiratory Muscle Strength, and Oxygen Consumption Predict Mortality in Patients with Cirrhosis. Can. J. Gastroenterol. Hepatol. 2016, 2016, 6940374. [Google Scholar] [CrossRef] [PubMed]
  26. Peel, N.M.; Kuys, S.S.; Klein, K. Gait speed as a measure in geriatric assessment in clinical settings: A systematic review. J. Gerontol. Ser. A Biomed. Sci. Med. Sci. 2013, 68, 39–46. [Google Scholar] [CrossRef] [PubMed]
  27. Maggio, M.; Ceda, G.P.; Ticinesi, A.; De Vita, F.; Gelmini, G.; Costantino, C.; Meschi, T.; Kressig, R.W.; Cesari, M.; Fabi, M.; et al. Instrumental and Non-Instrumental Evaluation of 4-Meter Walking Speed in Older Individuals. PLoS ONE 2016, 11, e0153583. [Google Scholar] [CrossRef] [PubMed]
  28. Henrique, D.M.N.; Mourao-Junior, C.A.; Pace, F.; Oliveira, T.M.D.; Malaguti, C.; Chebli, J. Six-minute walk test predicts future decompensation in patients with compensated liver cirrhosis. Rev. Assoc. Médica Bras. 2022, 68, 991–994. [Google Scholar] [CrossRef] [PubMed]
  29. Bischoff, H.A.; Stähelin, H.B.; Monsch, A.U.; Iversen, M.D.; Weyh, A.; von Dechend, M.; Akos, R.; Conzelmann, M.; Dick, W.; Theiler, R. Identifying a cut-off point for normal mobility: A comparison of the timed ’up and go’ test in community-dwelling and institutionalised elderly women. Age Ageing 2003, 32, 315–320. [Google Scholar] [CrossRef] [PubMed]
  30. Newman, A.B.; Simonsick, E.M.; Naydeck, B.L.; Boudreau, R.M.; Kritchevsky, S.B.; Nevitt, M.C.; Pahor, M.; Satterfield, S.; Brach, J.S.; Studenski, S.A.; et al. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA 2006, 295, 2018–2026. [Google Scholar] [CrossRef] [PubMed]
  31. Montano-Loza, A.J. Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl. 2014, 20, 1424. [Google Scholar] [CrossRef] [PubMed]
  32. Hanai, T.; Shiraki, M.; Nishimura, K.; Ohnishi, S.; Imai, K.; Suetsugu, A.; Takai, K.; Shimizu, M.; Moriwaki, H. Sarcopenia impairs prognosis of patients with liver cirrhosis. Nutrition 2015, 31, 193–199. [Google Scholar] [CrossRef] [PubMed]
  33. Tandon, P.; Ney, M.; Irwin, I.; Ma, M.M.; Gramlich, L.; Bain, V.G.; Esfandiari, N.; Baracos, V.; Montano-Loza, A.J.; Myers, R.P. Severe muscle depletion in patients on the liver transplant wait list: Its prevalence and independent prognostic value. Liver Transpl. 2012, 18, 1209–1216. [Google Scholar] [CrossRef] [PubMed]
  34. Tsien, C.; Garber, A.; Narayanan, A.; Shah, S.N.; Barnes, D.; Eghtesad, B.; Fung, J.; McCullough, A.J.; Dasarathy, S. Post-liver transplantation sarcopenia in cirrhosis: A prospective evaluation. J. Gastroenterol. Hepatol. 2014, 29, 1250–1257. [Google Scholar] [CrossRef] [PubMed]
  35. Meza-Junco, J.; Montano-Loza, A.J.; Baracos, V.E.; Prado, C.M.; Bain, V.G.; Beaumont, C.; Esfandiari, N.; Lieffers, J.R.; Sawyer, M.B. Sarcopenia as a prognostic index of nutritional status in concurrent cirrhosis and hepatocellular carcinoma. J. Clin. Gastroenterol. 2013, 47, 861–870. [Google Scholar] [CrossRef] [PubMed]
  36. Imai, K.; Takai, K.; Watanabe, S.; Hanai, T.; Suetsugu, A.; Shiraki, M.; Shimizu, M. Sarcopenia Impairs Prognosis of Patients with Hepatocellular Carcinoma: The Role of Liver Functional Reserve and Tumor-Related Factors in Loss of Skeletal Muscle Volume. Nutrients 2017, 9, 1054. [Google Scholar] [CrossRef] [PubMed]
  37. Tandon, P.; Low, G.; Mourtzakis, M.; Zenith, L.; Myers, R.P.; Abraldes, J.G.; Shaheen, A.A.; Qamar, H.; Mansoor, N.; Carbonneau, M.; et al. A Model to Identify Sarcopenia in Patients With Cirrhosis. Clin. Gastroenterol. Hepatol. 2016, 14, 1473–1480.e3. [Google Scholar] [CrossRef] [PubMed]
  38. Lai, J.C.; Sonnenday, C.J.; Tapper, E.B.; Duarte-Rojo, A.; Dunn, M.A.; Bernal, W.; Carey, E.J.; Dasarathy, S.; Kamath, B.M.; Kappus, M.R.; et al. Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice. Am. J. Transpl. Transplant. 2019, 19, 1896–1906. [Google Scholar] [CrossRef] [PubMed]
  39. Van Jacobs, A.C. Frailty Assessment in Patients with Liver Cirrhosis. Clin. Liver Dis. 2019, 14, 121–125. [Google Scholar] [CrossRef] [PubMed]
  40. Williams, F.R.; Berzigotti, A.; Lord, J.M.; Lai, J.C.; Armstrong, M.J. Review article: Impact of exercise on physical frailty in patients with chronic liver disease. Aliment. Pharmacol. Ther. 2019, 50, 988–1000. [Google Scholar] [CrossRef] [PubMed]
  41. Lai, J.C.; Dodge, J.L.; Kappus, M.R.; Wong, R.; Mohamad, Y.; Segev, D.L.; McAdams-DeMarco, M. A Multicenter Pilot Randomized Clinical Trial of a Home-Based Exercise Program for Patients With Cirrhosis: The Strength Training Intervention (STRIVE). Am. J. Gastroenterol. 2021, 116, 717–722. [Google Scholar] [CrossRef] [PubMed]
  42. Jones, J.C.; Coombes, J.S.; Macdonald, G.A. Exercise capacity and muscle strength in patients with cirrhosis. Liver Transpl. 2012, 18, 146–151. [Google Scholar] [CrossRef] [PubMed]
  43. Morkane, C.M.; Kearney, O.; Bruce, D.A.; Melikian, C.N.; Martin, D.S. An Outpatient Hospital-based Exercise Training Program for Patients With Cirrhotic Liver Disease Awaiting Transplantation: A Feasibility Trial. Transplantation 2020, 104, 97–103. [Google Scholar] [CrossRef] [PubMed]
  44. Wallen, M.P.; Keating, S.E.; Hall, A.; Hickman, I.J.; Pavey, T.G.; Woodward, A.J.; Skinner, T.L.; Macdonald, G.A.; Coombes, J.S. Exercise Training Is Safe and Feasible in Patients Awaiting Liver Transplantation: A Pilot Randomized Controlled Trial. Liver Transpl. 2019, 25, 1576–1580. [Google Scholar] [CrossRef] [PubMed]
  45. Chen, H.W.; Ferrando, A.; White, M.G.; Dennis, R.A.; Xie, J.; Pauly, M.; Park, S.; Bartter, T.; Dunn, M.A.; Ruiz-Margain, A.; et al. Home-Based Physical Activity and Diet Intervention to Improve Physical Function in Advanced Liver Disease: A Randomized Pilot Trial. Dig. Dis. Sci. 2020, 65, 3350–3359. [Google Scholar] [CrossRef] [PubMed]
  46. Williams, F.R.; Vallance, A.; Faulkner, T.; Towey, J.; Durman, S.; Kyte, D.; Elsharkawy, A.M.; Perera, T.; Holt, A.; Ferguson, J.; et al. Home-Based Exercise in Patients Awaiting Liver Transplantation: A Feasibility Study. Liver Transpl. 2019, 25, 995–1006. [Google Scholar] [CrossRef] [PubMed]
  47. Kruger, C.; McNeely, M.L.; Bailey, R.J.; Yavari, M.; Abraldes, J.G.; Carbonneau, M.; Newnham, K.; DenHeyer, V.; Ma, M.; Thompson, R.; et al. Home Exercise Training Improves Exercise Capacity in Cirrhosis Patients: Role of Exercise Adherence. Sci. Rep. 2018, 8, 99. [Google Scholar] [CrossRef] [PubMed]
  48. Berzigotti, A.; Albillos, A.; Villanueva, C.; Genescá, J.; Ardevol, A.; Augustín, S.; Calleja, J.L.; Bañares, R.; García-Pagán, J.C.; Mesonero, F.; et al. Ciberehd SportDiet Collaborative Group. Effects of an intensive lifestyle intervention program on portal hypertension in patients with cirrhosis and obesity: The SportDiet study. Hepatology 2017, 65, 1293–1305. [Google Scholar] [CrossRef] [PubMed]
  49. Jones, C.J.; Rikli, R.E.; Beam, W.C. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res. Q. Exerc. Sport 1999, 70, 113–119. [Google Scholar] [CrossRef] [PubMed]
  50. Terziyski, K.; Andonov, V.; Marinov, B.; Kostianev, S. Exercise performance and ventilatory efficiency in patients with mild and moderate liver cirrhosis. Clin. Exp. Pharmacol. Physiol. 2008, 35, 135–140. [Google Scholar] [CrossRef] [PubMed]
  51. Galant, L.H.; Forgiarini, L.A., Jr.; Dias, A.S. The aerobic capacity and muscle strength are correlated in candidates for liver transplantation. Arq. Gastroenterol. 2011, 48, 86–88. [Google Scholar] [CrossRef] [PubMed]
  52. Bay Nielsen, H.; Secher, N.H.; Clemmesen, O.; Ott, P. Maintained cerebral and skeletal muscle oxygenation during maximal exercise in patients with liver cirrhosis. J. Hepatol. 2005, 43, 266–271. [Google Scholar] [CrossRef] [PubMed]
  53. Lunzer, M.; Newman, S.P.; Sherlock, S. Skeletal muscle blood flow and neurovascular reactivity in liver disease. Gut 1973, 14, 354–359. [Google Scholar] [CrossRef] [PubMed]
  54. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Syst Rev 2021, 10, 89. [Google Scholar] [CrossRef] [PubMed]
  55. Zenith, L.; Meena, N.; Ramadi, A.; Yavari, M.; Harvey, A.; Carbonneau, M.; Ma, M.; Abraldes, J.G.; Paterson, I.; Haykowsky, M.J.; et al. Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin. Gastroenterol. Hepatol. 2014, 12, 1920–1926.e2. [Google Scholar] [CrossRef] [PubMed]
  56. Pimentel, C.F.M.G.; Amaral, A.C.C.; Gonzalez, A.M.; Lai, M.; Mota, D.O.; Ferraz, M.L.G.; Junior, W.M.; Kondo, M. Six-minute walking test performance is associated with survival in cirrhotic patients. World J. Hepatol. 2021, 13, 1791–1801. [Google Scholar] [CrossRef] [PubMed]
  57. Cox-Flaherty, K.; Moutchia, J.; Krowka, M.J.; Al-Naamani, N.; Fallon, M.B.; DuBrock, H.; Forde, K.A.; Krok, K.; Doyle, M.F.; Kawut, S.M.; et al. Six-Minute walk distance predicts outcomes in liver transplant candidates. Liver Transpl. 2023, 29, 521–530. [Google Scholar] [CrossRef] [PubMed]
  58. Al-Judaibi, B.; Alqalami, I.; Sey, M.; Qumosani, K.; Howes, N.; Sinclair, L.; Chandok, N.; Eddin, A.H.; Hernandez-Alejandro, R.; Marotta, P.; et al. Exercise Training for Liver Transplant Candidates. Transpl. Transplant. Proc. 2019, 51, 3330–3337. [Google Scholar] [CrossRef] [PubMed]
  59. Aamann, L.; Dam, G.; Jepsen, P.; Borre, M.; Drljevic-Nielsen, A.; Overgaard, K.; Andersen, H.; Vilstrup, H.; Aagaard, N.K. Reduced 3-year risk of hospital admission and mortality after 12-week resistance training of cirrhosis patients: A follow-up of a randomized clinical trial. J. Gastroenterol. Hepatol. 2023, 38, 1365–1371. [Google Scholar] [CrossRef] [PubMed]
  60. Nóbrega, S.R.; Chachá, S.G.F.; Libardi, C.A. Resistance training combined with blood flow restriction in cirrhosis: Study protocol for a randomized controlled trial. Trials 2020, 21, 446. [Google Scholar] [CrossRef] [PubMed]
  61. Sirisunhirun, P.; Bandidniyamanon, W.; Jrerattakon, Y.; Muangsomboon, K.; Pramyothin, P.; Nimanong, S.; Tanwandee, T.; Charatcharoenwitthaya, P.; Chainuvati, S.; Chotiyaputta, W. Effect of a 12-week home-based exercise training program on aerobic capacity, muscle mass, liver and spleen stiffness, and quality of life in cirrhotic patients: A randomized controlled clinical trial. BMC Gastroenterol. 2022, 22, 66. [Google Scholar] [CrossRef] [PubMed]
  62. Thuluvath, A.J.; Polineni, P.; Morrissey, S.; Belfanti, K.; Nizamuddin, M.; Siddiqui, O.; Daud, A.; Simpson, D.C.; Levitsky, J.; Flores, A.M.; et al. Home-based LIver FrailTy Intervention (LIFT) in Transplant Candidates: A Feasibility Study. Transplantation 2025, 109, e202–e212. [Google Scholar] [CrossRef] [PubMed]
  63. Aamann, L.; Dam, G.; Borre, M.; Drljevic-Nielsen, A.; Overgaard, K.; Andersen, H.; Vilstrup, H.; Aagaard, N.K. Resistance Training Increases Muscle Strength and Muscle Size in Patients With Liver Cirrhosis. Clin. Gastroenterol. Hepatol. 2020, 18, 1179–1187.e6. [Google Scholar] [CrossRef] [PubMed]
  64. Moya-Nájera, D.; Moya-Herraiz, Á.; Compte-Torrero, L.; Hervás, D.; Borreani, S.; Calatayud, J.; Berenguer, M.; Colado, J.C. Combined resistance and endurance training at a moderate-to-high intensity improves physical condition and quality of life in liver transplant patients. Liver Transpl. 2017, 23, 1273–1281. [Google Scholar] [CrossRef] [PubMed]
  65. Yüksel Ergene, T.; Karadibak, D.; Dönmez, R.; Polat, K.Y. Effects of Early Resistance Training After Liver Transplantation Procedures: A Randomized Controlled Pilot Trial. Turk. J. Gastroenterol. 2022, 33, 852–861. [Google Scholar] [CrossRef] [PubMed]
  66. Vestergaard, S.; Patel, K.V.; Bandinelli, S.; Ferrucci, L.; Guralnik, J.M. Characteristics of 400-meter walk test performance and subsequent mortality in older adults. Rejuvenation Res. 2009, 12, 177–184. [Google Scholar] [CrossRef] [PubMed]
  67. Chow, L.S.; Gerszten, R.E.; Taylor, J.M.; Pedersen, B.K.; van Praag, H.; Trappe, S.; Febbraio, M.A.; Galis, Z.S.; Gao, Y.; Haus, J.M.; et al. Exerkines in health, resilience and disease. Nat. Rev. Endocrinol. 2022, 18, 273–289. [Google Scholar] [CrossRef] [PubMed]
  68. Soldera, J.; Freitas, L.F.; Rech, A.; Rossi, D.; Onzi, G.; Heinrich, C.F.; Turella, D.J.P.; Weber, T.A.S.; Oliveira, M.L. Resistance training effects on quality of life and fatigue for compensated cirrhotic patients: Preliminary results from a randomized controlled trial. UEG Week Virtual 2020. United Eur. Gastroenterol. J. 2020, 8 (Suppl. S1). Available online: https://www.nxtbook.com/ueg/UEG/Abstracts/index.php (accessed on 29 March 2025).
  69. Soldera, J.; Rech, A.; Rossi, D.; Freitas, L.F.; Onzi, G.; Heinrich, C.F.; Turella, D.J.P.; Weber, T.A.S.; Oliveira, M.L.; Lopez, P.; et al. Resistance training effects on muscle strength and muscle mass in compensated cirrhotic patients: Preliminary results from a randomized controlled trial. UEG Week Virtual 2020. United Eur. Gastroenterol. J. 2020, 8 (Suppl. S1). Available online: https://www.nxtbook.com/ueg/UEG/Abstracts/index.php#/p/619/OnePage (accessed on 29 March 2025).
  70. Soldera, J.; Rossi, D.; d’Avila, A.F.; Galant, L.H.; Marroni, C.A. Physical rehabilitation in the cirrhotic patient: Results from a clinical trial. UEG Week Virtual 2020. United Eur. Gastroenterol. J. 2020, 8 (Suppl. S1). Available online: https://www.nxtbook.com/ueg/UEG/Abstracts/index.php#/p/623/OnePage (accessed on 29 March 2025).
  71. Wongtrakul, W.; Bandidniyamanon, W.; Charatcharoenwitthaya, P. Relationship between Sarcopenia and minimal hepatic encephalopathy in patients with cirrhosis: A prospective observational study. BMC Gastroenterol. 2025, 25, 88. [Google Scholar] [CrossRef]
Livers 05 00025 g001
Figure 1. PRISMA-P flowchart for selected studies. * Databases = PubMed/MEDLINE. ** Reports excluded after first screening.
Figure 1. PRISMA-P flowchart for selected studies. * Databases = PubMed/MEDLINE. ** Reports excluded after first screening.
Livers 05 00025 g001
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Vellatt, S.; Soldera, J. From Prehabilitation to Rehabilitation: A Systematic Review of Resistance Training as a Strategy to Combat Sarcopenia in Pre- and Post-Liver Transplant Patients. Livers 2025, 5, 25. https://doi.org/10.3390/livers5020025

AMA Style

Vellatt S, Soldera J. From Prehabilitation to Rehabilitation: A Systematic Review of Resistance Training as a Strategy to Combat Sarcopenia in Pre- and Post-Liver Transplant Patients. Livers. 2025; 5(2):25. https://doi.org/10.3390/livers5020025

Chicago/Turabian Style

Vellatt, Sooraj, and Jonathan Soldera. 2025. "From Prehabilitation to Rehabilitation: A Systematic Review of Resistance Training as a Strategy to Combat Sarcopenia in Pre- and Post-Liver Transplant Patients" Livers 5, no. 2: 25. https://doi.org/10.3390/livers5020025

APA Style

Vellatt, S., & Soldera, J. (2025). From Prehabilitation to Rehabilitation: A Systematic Review of Resistance Training as a Strategy to Combat Sarcopenia in Pre- and Post-Liver Transplant Patients. Livers, 5(2), 25. https://doi.org/10.3390/livers5020025

Article Metrics

Back to TopTop