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Intramuscular fat accumulation has come to be associated with loss of muscle strength and function, one of the components of sarcopenia. However, the impact of preoperative quality of skeletal muscle on outcomes after living donor liver transplantation (LDLT) is unclear. The present study evaluated the intramuscular adipose tissue content (IMAC) and psoas muscle mass index (PMI) in 200 adult patients undergoing LDLT at our institution between January 2008 and October 2013. Correlations of IMAC with other factors, overall survival rates in patients classified according to IMAC or PMI, and risk factors for poor survival after LDLT were analyzed. IMAC was significantly correlated with age (r 5 0.229, P 5 0.03) and PMI (r 5 20.236, P 5 0.02) in males and with age (r 5 0.349, P < 0.001) and branched-chain amino acid (BCAA)-to-tyrosine ratio (r 5 20.250, P 5 0.01) in females. The overall survival rates in patients with high IMAC or low PMI were significantly lower than those for patients with normal IMAC or PMI (P < 0.001, P < 0.001, respectively). Multivariate analysis showed that high IMAC [odds ratio (OR) 5 3.898, 95% confidence interval (CI) 5 2.025-7.757, P < 0.001] and low PMI (OR 5 3.635, 95% CI 5 1.896-7.174, P < 0.001) were independent risk factors for death after LDLT. In conclusion, high IMAC and low PMI were closely involved with posttransplant mortality. Preoperative quality and quantity of skeletal muscle could be incorporated into new selection criteria for LDLT. Perioperative nutritional therapy and rehabilitation could be important for good outcomes after LDLT. See Editorial on Page 1293Sarcopenia is defined as a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength, with a risk of adverse outcomes such as physical disability, poor quality of life, and death. 1 Recent evidence has shown that sarcopenia is an independent predictor of lower disease-free and overall survival in various kinds of diseases. [2][3][4] In patients with liver cirrhosis (LC), protein malnutrition, which is caused by decreased protein synthesis and disturbed energy metabolism, can cause a decrease in skeletal muscle mass. In recent studies, sarcopenia was found to be present in approximately one-third of patients with hepatocellular carcinoma (HCC) and LC who were being evaluated for liver transplantation (LT), and sarcopenia was found to be an independent prognostic factor for overall and recurrence-

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