Transjugular Intrahepatic Portosystemic Shunt With or Without Branched-Chain Amino Acid Supplements in the Treatment of Patients With Cirrhotic Portal Hypertension Complicated by Sarcopenia: A Randomized Controlled Trial

Cirrhosis is a major cause of morbidity and mortality among patients with chronic liver disease worldwide. In 2019, cirrhosis accounted for 2.4% of global deaths. A Global Burden of Disease study (1990-2017) showed that the number of deaths caused by cirrhosis has been on the rise year by year since 1990, imposing a severe health and economic burden on many countries and peoples around the world. Cirrhosis is usually accompanied by the development of portal hypertension, which further leads to complications such as ascites, gastroesophageal variceal bleeding, and hepatic encephalopathy (HE). Among these, the mortality rate of gastroesophageal variceal bleeding reaches as high as 20% within 6 weeks of onset. Currently, according to guidelines issued by the European Association for the Study of the Liver (EASL), the American Association for the Study of Liver Diseases (AASLD), and the Chinese Medical Association, transjugular intrahepatic portosystemic shunt (TIPS) has become an important treatment for variceal bleeding and refractory ascites.

Malnutrition is a common complication of cirrhosis, affecting 20% of patients with compensated cirrhosis and more than 50% of those with decompensated cirrhosis. Sarcopenia is generally regarded as severe malnutrition, and its occurrence is often associated with a higher risk of cirrhosis-related complications (such as hepatic encephalopathy, ascites, and infections), which seriously impairs patients' quality of life and survival. Several studies have shown that sarcopenia is associated with poor prognosis in cirrhotic patients undergoing TIPS treatment. Therefore, concurrent intervention for sarcopenia during TIPS treatment may improve prognosis and thus enhance patient survival.

The Baveno VII guidelines point out that malnutrition increases the risk of poor prognosis in patients with cirrhosis and acute variceal bleeding, and oral nutrition should be initiated as soon as possible. Both the EASL Clinical Practice Guidelines on Nutrition in Chronic Liver Disease and the AASLD Practice Guidance on Malnutrition, Frailty, and Sarcopenia in Patients with Cirrhosis recommend the use of branched-chain amino acid (BCAA) supplements and leucine-rich amino acid supplements in patients with decompensated cirrhosis to achieve adequate nitrogen intake. An RCT study demonstrated that BCAA supplements can improve the skeletal muscle index (SMI) in cirrhotic patients with sarcopenia. Additionally, evidence suggests that BCAA supplements can significantly reduce the risk of hepatic encephalopathy (HE).

Therefore, BCAA supplements may serve as a routine nutritional supplement for cirrhotic patients undergoing TIPS treatment, but relevant evidence is currently lacking. This study aims to compare changes in muscle mass and clinical prognosis between cirrhotic patients with portal hypertension and variceal bleeding complicated by sarcopenia who receive TIPS with or without BCAA supplements, so as to verify our hypothesis.