A new definition of sarcopenia in patients with cirrhosis undergoing liver transplantation

Abstract

Although sarcopenia is a common complication of cirrhosis, its diagnosis remains nonconsensual: computed tomography (CT) scan determinations vary and no cutoff values have been established in cirrhotic populations undergoing liver transplantation (LT). Our aim was to compare the accuracy of the most widely used measurement techniques and to establish useful cutoffs in the setting of LT. From the 440 patients transplanted between January 2008 and May 2011 in our tertiary center, we selected 256 patients with cirrhosis for whom a recent CT scan was available during the 4 months prior to LT. We measured different muscle indexes: psoas muscle area (PMA), PMA normalized by height or body surface area (BSA), and the third lumbar vertebra skeletal muscle index (L3SMI). Receiver operating characteristic curves were evaluated and prognostic factors for post-LT 1-year survival were then analyzed. PMA offered better accuracy (area under the curve [AUC] = 0.753) than L3SMI (AUC = 0.707) and PMA/BSA (AUC = 0.732), and the same accuracy as PMA/squared height. So, for its accuracy and simplicity of use, the PMA index was used for the remainder of the analysis and to define sarcopenia. In men, the better cutoff value for PMA was 1561 mm (Se = 94%, Sp = 57%), whereas in women, it was 1464 mm (Se = 52%, Sp = 91%). A PMA lower than these values defined sarcopenia in patients with cirrhosis awaiting LT. One- and 5-year overall survival rates were significantly poorer in the sarcopenic group (n = 57) than in the nonsarcopenic group (n = 199), at 59% versus 94% and 54% versus 80%, respectively (P < 0.001). In conclusion, pre-LT PMA is a simple tool to assess sarcopenia. We established sex-specific cutoff values (1561 mm in men, 1464 mm in women) in a cirrhotic population and showed that 1-year survival was significantly poorer in sarcopenic patients. Liver Transplantation 23 143-154 2017 AASLD.

Relationship Between Total Body Protein and Cross‐Sectional Skeletal Muscle Area in Liver Cirrhosis Is Influenced by Overhydration

“…Sarcopenia and protein‐energy malnutrition are common in patients with chronic liver disease, affecting up to 70% of patients on the waiting list for liver transplantation . Several studies have demonstrated strong associations between sarcopenia and wait‐list mortality as well as short‐term and longterm outcomes following transplantation . Similar trends have also been described for patients with abdominal malignancies and those undergoing major surgery .…”

“…The skeletal muscle index (SMI) and psoas muscle index (PMI) were calculated by dividing SMA and PMA, respectively, by height squared and expressed as cm 2 /m 2 . These values were used to determine sarcopenia according to several published cutoffs that have been derived in cirrhotic and noncirrhotic cohorts …”

“…Given its strong association with clinical outcomes, some authors have proposed using sarcopenia as an objective prognostic indicator in the assessment of patients for transplantation. However, no consensus exists on the most appropriate definitions, cutoffs, or techniques for clinical use …”

Perioperative loss of psoas muscle is associated with patient survival in living donor liver transplantation

“…There have been a few studies regarding the association between preoperative sarcopenia and overall patient mortality in the LT setting . In detail, central sarcopenia, using the cross‐sectional PMA at the fourth lumbar vertebra level (LVL), was regarded as an indicator of patient frailty, and this parameter was closely related to mortality in LT .…”

“…The underlying pathway resulting in sarcopenia in ESLD patients is complex, and involves malnutrition, limited physical activity, hormonal alterations, and changes in the composition of the intestinal microbiome . Although evidence of sarcopenia has accumulated in patients with ESLD, the impact of sarcopenia on postoperative outcome in an LT setting has been clarified . Independent of MELD score, which is an indicator of the severity of hepatic decompensation and is used for allocation of liver grafts, preoperative sarcopenia itself was clearly associated with early prognosis after LT .…”