Physical frailty is a biological syndrome characterized by a cumulative decline in physiologic reserve, including loss of muscle strength and contractility, which leads to impaired physical function and increased vulnerability to adverse clinical outcomes.1 This multifactorial condition arises from deterioration across several physiological aspects, most notably the musculoskeletal, cardiovascular, and immune systems.2–4 Frailty is one of the most prevalent manifestations of cirrhosis and significantly contributes to adverse clinical outcomes, particularly increased morbidity and mortality.5 According to the widely established Fried frailty phenotype, physical frailty is characterized by exhaustion, reduced grip strength, slow gait speed, and low physical activity; individuals meeting three or more of these criteria are classified as frail.2

Among individuals with cirrhosis listed for liver transplantation, frailty has been independently linked to greater waitlist mortality and more frequent unplanned hospitalizations.6

A recent meta-analysis demonstrated that the pooled prevalence of frailty in patients with cirrhosis is 27% (95% CI 21-33%), and when compared with non-frail patients, frail patients tend to be male, older, and have a lower body mass index and poor liver function.7

Despite its clinical importance, the pathophysiology of frailty in cirrhosis is not yet fully understood.1

Currently, the primary tool for assessing frailty in cirrhosis is the Liver Frailty Index (LFI), a validated and objective measure incorporating handgrip strength, timed chair stands (5 repetitions), and balance testing (side-by-side, semi-tandem, and tandem holds). The LFI classifies patients as robust (LFI < 3.2), pre-frail (LFI 3.2 to < 4.5), or frail (LFI ≥ 4.5). Additional frailty assessments used in cirrhosis include the Short Physical Performance Battery (SPPB), which evaluates gait speed, balance, and chair stands; as well as self-reported functional tools such as the Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). While ADLs assess a patient’s ability to perform basic self-care, IADLs measure more complex daily functions, such as meal preparation or managing finances. Notably, limitations in ADLs are strong predictors of mortality in patients with cirrhosis.6

Similarly, malnutrition is a frequent complication of cirrhosis and has a significant impact on disease severity, affecting approximately 20% of patients with compensated liver disease and up to 80% of those with decompensated disease.8,9 In patients with cirrhosis, malnutrition is a major driver of sarcopenia, a central component of physical frailty.10,11 Although frailty has been investigated across different causes of cirrhosis, existing studies largely evaluate individuals with established cirrhosis, and data in patients with HCV-related chronic liver disease remain scarce (Table 1).

In this issue of the Revista de Gastroenterología de México, Vázquez-Rodríguez et al.12 provide information on frailty and dietary intake quality in patients with chronic HCV infection, as well as the association between demographic, clinical, and anthropometric variables. In this study, the authors evaluated 52 patients with HCV infection, of whom 60% had cirrhosis, primarily compensated disease (Child-Pugh A and B). Frailty was assessed using the LFI, and none of the participants were classified as robust; more than 80% were pre-frail, and 19% were frail. The mean handgrip strength was 25.5 ± 11.1 kg, indicating moderate weakness in this cohort. Nutritional status was evaluated using triceps skinfold thickness (TSF) and mid-arm muscle circumference (MAMC), which demonstrated a greater prevalence of reduced muscle mass compared with decreased fat stores. Dietary quality, assessed using the Mini-ECCA v.2, revealed that fewer than 10% of individuals met criteria for a healthy diet.

The study by Vázquez-Rodríguez et al. is particularly relevant because it highlights the high frequency of physical frailty in Hispanic individuals with HCV-related liver disease, underscoring the need for systematic frailty screening in this population. In addition, the study demonstrates an association between frailty and poor dietary habits, suggesting a potential modifiable factor in the management of these patients.

Nevertheless, several limitations in this study warrant consideration. The sample size was small, restricting the ability to conduct subgroup analyses, and participants were enrolled from a single center, limiting generalizability. Furthermore, the cross-sectional design precludes establishing a causal relationship between dietary quality and frailty. Finally, muscle mass was not assessed using gold-standard imaging modalities, such as computed tomography (CT), which would have provided a more precise characterization of sarcopenia.13

In conclusion, the current study by Vázquez-Rodríguez et al.12 highlights a high prevalence of frailty among patients with chronic liver disease related to HCV, associated with inadequate dietary intake quality. Furthermore, the positive correlation between anthropometric measures of muscle mass and handgrip strength emphasizes the importance of objective evaluations of muscle mass and strength. However, longitudinal studies with a larger number of patients from different centers are required, to clarify the causal relationship between frailty and dietary intake in HCV-related cirrhosis etiology. Muscle mass evaluation using CT is considered the gold standard method, providing more detailed and precise information, and is recommended for future studies. Such studies could provide insight into how nutritional interventions, dietary optimization, and early muscle mass preservation in different populations might affect the survival, complications, and quality of life of the patients.