Exercise in cirrhosis: Translating evidence and experience to practice Puneeta Tandon, Kathleen Patricia Ismond, Kenneth Riess, Andres Duarte-Rojo, Bandar Al-Judaibi, Michael Andrew Dunn, Jennifer Holman, Nancy Howes, Mark Joseph Franklin Haykowsky, Deborah Ann Josbeno, Margaret McNeely  Journal of Hepatology  Volume 69, Issue 5, Pages 1164-1177 (November 2018) DOI: 10.1016/j.jhep.2018.06.017 Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 1 Benefits of exercise for the patient with cirrhosis. Exercise has multiple benefits, resulting from both central (cardiovascular and pulmonary) adaptations and peripheral adaptations. A simplified version of this Figure is provided in the supplementary materials – patient package. Journal of Hepatology 2018 69, 1164-1177DOI: (10.1016/j.jhep.2018.06.017) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions

Fig. 2 Elevated ammonia as a cause for sarcopenia in cirrhosis. Hyperammonemia from impaired hepatic detoxification affects skeletal muscle by 1) causing intracellular amino acid depletion in association with production and export of glutamine (what is metabolised back to ammonia in extra-muscular tissues, thus perpetuating damage); 2) blocking of mammalian target of rapamycin complex 1 and affecting protein anabolism; and 3) increasing myostatin expression and favoring skeletal muscle catabolism. Experimental data also substantiates a role for hyperammonemia in promoting skeletal muscle autophagy. BCAA, branch-chain amino acids; GCN2, general control non-depressible 2 (amino acid deficiency sensor); GLN, glutamine; GLU, glutamate; GLS1, glutaminase; GS, glutamine synthetase; mTORC1, mammalian target of rapamycin complex 1; NH3, ammonia. Journal of Hepatology 2018 69, 1164-1177DOI: (10.1016/j.jhep.2018.06.017) Copyright © 2018 European Association for the Study of the Liver Terms and Conditions