Muscle depletion or sarcopenia is associated with increased mortality in patients with cirrhosis; how it affects mortality after liver transplantation requires further study. In this study, we aimed to establish whether sarcopenia predicts increased morbidity or mortality after liver transplantation. We analyzed 248 patients with cirrhosis who had a computed tomography (CT) scan including the third lumbar vertebra before liver transplantation. Data were recovered from medical charts, the skeletal muscle cross-sectional area was measured with CT, and sarcopenia was defined with previously published sex-and body mass index-specific cutoffs. One hundred sixty-nine patients (68%) were male, and the mean age at transplantation was 55 6 1 years. The etiologies of cirrhosis were hepatitis C virus (51%), alcohol (19%), autoimmune liver diseases (15%), hepatitis B virus (8%), and other etiologies (7%). Sarcopenia was present in 112 patients (45%), and it was more frequent in males (P 5 0.002), patients with ascites (P 5 0.02), and patients with higher bilirubin levels (P 5 0.05), creatinine levels (P 5 0.02), international normalized ratios (P 5 0.04), Child-Pugh scores (P 5 0.002), and Model for End-Stage Liver Disease scores (P 5 0.002). The median survival period after liver transplantation was 117 6 17 months for sarcopenic patients and 146 6 20 months for nonsarcopenic patients (P 5 0.4). Sarcopenic patients had longer hospital stays (40 6 4 versus 25 6 3 days; P 5 0.005) and a higher frequency of bacterial infections within the first 90 days after liver transplantation (26% versus 15%, P 5 0.04) in comparison with nonsarcopenic patients. In conclusion, sarcopenia is one of the most common complications in patients with cirrhosis and is predictive of longer hospital stays and a higher risk of perioperative bacterial infections after liver transplantation, but it is not associated with increased mortality. Liver Transpl 20:640-648, 2014. V C 2014 AASLD.

Quality of life (QOL) is a phrase which was first used shortly after the Second World War and has, since then, been overused and infrequently defined. A concept analysis of QOL is presented to clarify the concept for further use. The process for concept analysis developed by Walker & Avant is employed. Quality of life is found to be very complex, and it is hoped that this analysis will stimulate thought and further nursing research into what QOL means in the health care context.

The selection of liver transplant candidates with hepatocellular carcinoma (HCC) is currently validated based on Milan criteria. The use of extended criteria has remained a matter of debate, mainly because of the absence of prospective validation. The present prospective study recruited patients according to the previously proposed Total Tumor Volume (TTV ≤115 cm 3 )/ alpha fetoprotein (AFP ≤400 ng/ml) score. Patients with AFP >400 ng/ml were excluded, and as such the Milan group was modified to include only patients with AFP <400 ng/ml; these patients were compared to patients beyond Milan, but within TTV/AFP. From January 2007 to March 2013, 233 patients with HCC were listed for liver transplantation. Of them, 195 patients were within Milan, and 38 beyond Milan but within TTV/AFP. The average follow-up from listing was 33,9 ±24,9 months.The risk of drop-out was higher for patients beyond Milan but within TTV/AFP (16/38, 42,1%), than for patients within Milan (49/195, 25,1%, p=0,033). In parallel, intent-totreat survival from listing was lower in the patients beyond Milan (53,8% vs. 71,6% at four years, p<0,001). After a median waiting time of 8 months, 166 patients were transplanted, 134 patients within Milan criteria, and 32 beyond Milan but within TTV/AFP. They demonstrated acceptable and similar recurrence rates (4,5% vs. 9,4%, p=0,138) and post-transplant survivals (78,7% vs. 74,6% at four years, p=0,932). Conclusion:Based on the present prospective study, HCC liver transplant candidate selection could be expanded to the TTV (≤115 cm 3 )/ AFP (≤400 ng/ml) criteria in centers with at least 8-month waiting time. An increased risk of drop-out on the waiting list can be expected but with equivalent and satisfactory post-transplant survival.

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