Ultrasound-Based Skeletal Muscle Assessment for Prognostication in Cirrhosis: A Systematic Review

Sarcopenia is a major determinant of adverse outcomes in cirrhosis, yet CT- and MRI-based assessments are difficult to implement in routine and longitudinal practice. Ultrasound is a feasible bedside alternative, but its prognostic role remains unclear. We performed a systematic review to evaluate the association between ultrasound-derived skeletal muscle measures and mortality in adults with cirrhosis.

This review followed PRISMA guidelines and was registered in PROSPERO (CRD420251056162). MEDLINE, Scopus, Web of Science and the Cochrane Library were searched to October 2025. Prospective studies assessing ultrasound-based muscle parameters and mortality in cirrhosis were included. Risk of bias was evaluated using QUIPS.

Six prospective studies (n = 731) were included. Heterogeneity in muscle sites, ultrasound protocols, indexation methods, sarcopenia definitions and outcomes precluded meta-analysis. Lower ultrasound-derived muscle measures were consistently associated with higher mortality. In acute decompensation, reduced rectus femoris area predicted 90-day mortality (sHR 0.57; 95% CI 0.38-0.85). Rectus abdominis thickness and psoas indices were also associated with mortality. In hospitalized decompensated cirrhosis, ultrasound-defined sarcopenia was strongly associated with 6-month mortality (HR 6.37; 95% CI 3.15-12.87). In critically ill liver transplant candidates, higher serial rectus femoris muscle area measurements were associated with better survival. In advanced chronic liver disease, sarcopenia was linked to increased 1-year mortality.

In our systematic review, ultrasound-based muscle measures demonstrated a broadly consistent association with mortality; although not yet fully validated, they represent a promising bedside prognostic tool. Standardization is needed before clinical implementation.