Sarcopenia Predicts Mortality and Hepatic Encephalopathy After TIPS in Older Adults With Cirrhosis and Improves Prognostic Scores

Background and Aims: The role of transjugular intrahepatic portosystemic shunt (TIPS) in older adults remains controversialbecause of limited risk-stratification tools. We aimed to assess whether sarcopenia and myosteatosis are independently associ-ated with post-TIPS mortality and overt hepatic encephalopathy (OHE) in patients aged ≥ 70 years, and whether adding sarcope-nia to established prognostic scores improves discrimination for post-TIPS mortality.Methods: This multicenter retrospective study included 115 consecutive patients with cirrhosis aged ≥ 70 years undergoing TIPSfor refractory ascites or secondary prophylaxis of variceal bleeding. Sarcopenia and myosteatosis were assessed by computedtomography at L3. Post-TIPS mortality and time to first OHE episode were analysed using Kaplan–Meier and Cox regression.Sarcopenia was integrated into established prognostic scores, and predictive performance was evaluated using time-dependentROC analyses. 2 of 14 Liver International, 2026Results: Sarcopenia and myosteatosis were present in 60% and 80% of patients, respectively. During follow-up, 49% died and45% developed OHE. Sarcopenia was independently associated with both mortality and OHE, whereas myosteatosis and adipose-tissue indices were not. Incorporating sarcopenia improved the discriminative performance of all scores, with MELD 3.0–sar-copenia showing the highest accuracy (AUC 0.845). Predicted survival probabilities clearly separated patients across MELD3.0 categories according to sarcopenia status. For OHE, sarcopenia increased the risk while underdilated TIPS was protective,defining four distinct risk profiles.Conclusions: Sarcopenia is highly prevalent and independently predicts both mortality and OHE after TIPS in older adults. Its inte-gration into prognostic tools enhances risk stratification and supports individualised decision-making in this vulnerable population