Inclusion of Sarcopenia Within MELD (MELD-Sarcopenia) and the Prediction of Mortality in Patients With Cirrhosis

Abstract

OBJECTIVES:Limitations of the Model for End-Stage Liver Disease (MELD) score include its failure to assess the nutritional and functional status of cirrhotic patients. Our objectives were to evaluate the impact of sarcopenia in cirrhosis and whether the inclusion of muscularity assessment within MELD could improve the prediction of mortality in patients with cirrhosis.METHODS:We included 669 cirrhotic patients who were consecutively evaluated for liver transplantation. Skeletal muscle index at the third lumbar vertebra (L3 SMI) was measured by computed tomography, and sarcopenia was defined using previously published gender and body mass index–specific cutoffs. Using Cox proportional hazards regression, a novel MELD-sarcopenia score was derived.RESULTS:Sarcopenia was present in 298 patients (45%); sarcopenic patients had shorter median survival than non-sarcopenic patients (20±3 vs. 95±24 months, P<0.001). By Cox regression analysis adjusted for age, gender, and hepatocellular carcinoma, both MELD (hazard ratio (HR) 1.08, 95% confidence interval (CI) 1.06–1.10, P<0.001), and the L3 SMI (HR 0.97, 95% CI 0.96–0.99, P<0.001) were associated with mortality. Overall, the c-statistics for 3-month mortality were 0.82 (95% CI 0.78–0.87) for MELD and 0.85 (95% CI 0.81–0.88) for MELD-sarcopenia (P=0.1). Corresponding figures for 1-year mortality were 0.73 (95% CI 0.69–0.77) and 0.77 (95% CI 0.73–0.80), respectively (P=0.03). The c-statistics for 3-month mortality in patients with MELD<15 (0.85 vs. 0.69, P=0.02) and refractory ascites (0.74 vs. 0.71, P=0.01) were significantly higher for MELD-sarcopenia compared with MELD.CONCLUSIONS:Modification of MELD to include sarcopenia is associated with improved prediction of mortality in patients with cirrhosis, primarily in patients with low MELD scores. External validation of this prognostic index in larger cohorts of cirrhotic patients is warranted.

Systematic Review and Meta-Analysis of the Impact of Computed Tomography–Assessed Skeletal Muscle Mass on Outcome in Patients Awaiting or Undergoing Liver Transplantation

“…The outcome of this systematic review supports that sarcopenic liver transplant candidates face a worsened outcome. Besides the superiority of the MELD psoas area score of Durand et al to the MELD score and MELDNa score to predict waiting list mortality (15), the predictive value of the MELD sarcopenia score was found to be superior to the MELD score in a recent study (40). However, validation of these scores is recommended.…”

The utility of pulmonary function testing in predicting outcomes following liver transplantation

“…Studies have found that patients with significant sarcopenia (measured using the skeletal muscle index at the third lumbar vertebra) have worse pre-LT survival, and inclusion of sarcopenia into the MELD score may have value in predicting outcomes. (11,12) Furthermore, measures of frailty, such as activities of daily living, the Braden Scale, and the Morse fall risk score (standardized measures of frailty), have been found to be predictive of 90-day mortality, LOS, and need for rehabilitation for hospitalized patients with cirrhosis. (13) Additionally, markers of patient function, including the 6-minute walk test, (14) evaluation of maximum inspiratory pressure and maximum expiratory pressure using manometry, and surface electromyography of the diaphragm and rectus abdominis muscles, have shown that patients with cirrhosis have increased respiratory muscle weakness compared to controls.…”

Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation

“…Finally, because current methods used to assess liver disease severity, such as the Model for EndStage Liver Disease (MELD) score, do not give a functional assessment of the patient's fitness, we believe that the next step is to evaluate the development of composite scores, including new scores such as MELD-sarcopenia and MELD-psoas, 5,6 or to assign exemption points to those patients with sarcopenia so that they can undergo transplantation before they develop extreme sarcopenia. Nevertheless, this issue should be evaluated preferentially in prospective and multicenter controlled clinical trials.…”