No abstract

We read with great interest the study by Mauro et al., in which they devised the "Sarcopenia HIBA score" that predicts sarcopenia and mortality in patients on the liver transplant wait list. [1] We congratulate the authors for proposing a simple score that predicts the presence of sarcopenia and wait-list mortality in patients with cirrhosis.However, we want to highlight certain reservations about this score and the issue of sarcopenia assessment as a whole. The authors mentioned the area under the receiver operating characteristic curve (AUROC) value of 0.862 of the sarcopenia HIBA score at a cutoff value of −2.09 with an accuracy of 61.4%. We suggest that it would have been prudent to compare the AUROC of this score with an established prognostic score like Model for End-Stage Liver Disease sarcopenia, [2] which could have given more weight to the score. The authors do mention the disadvantages of computed tomography (CT)-based skeletal muscle index (SMI) in justifying the development of the sarcopenia HIBA score. However, the inclusion of cystatin-C as one of its components also complicates the application of this score because of limited availability beyond research laboratories and the expense involved. Many previous studies have shown that simple bedside tests of sarcopenia assessment like handgrip strength, gait speed, and chair stands correlate strongly with CT-based SMI, and predict mortality in patients with cirrhosis. [3,4] The analysis of data of 116 patients (unpublished) at our center also showed a strong correlation between CT-based SMI and handgrip strength (Spearman's correlation coefficient, ρ = 0.78) and gait speed (ρ = 0.65). The differences in AUROC plotted for CT-based SMI (0.80), gait speed (0.91), and handgrip strength (0.86) as a predictor of mortality were not significant (p > 0.05), implying that these bedside tests are equally good in predicting mortality in patients with cirrhosis. Hence, we suggest that large multicenter studies should be done to validate and establish these simple bedside tests for the diagnosis of sarcopenia. This would be helpful in resource-constrained countries, where there is limited availability of CT scans and laboratory facilities for measuring cystatin-c levels.