This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Abbreviations: AASLD American Association for the Study of Liver Diseases AUC area under the curve AUROC area under the receiver operating characteristics curve BAR balance of risk BC body composition BMI body mass index CCI comprehensive complication index CDC lavien-Dindo classification CT computed tomography EAD early allograft dysfunction EASL European Association for the Study of the Liver ECD extended criteria donor FFP unitsfresh frozen plasma units HU Hounsfield unit ICH International Conference on Harmonisation ICU Intensive Care Unit KPS Karnofsky Performance Score MELD Model of End-stage Liver Disease OLT orthotopic liver transplantation RBC units red blood cell units ROC receiver operating characteristics SM-RA skeletal muscle radiation attenuation SMI skeletal muscle index SMM skeletal muscle mass SOFT survival outcomes following liver transplantation TEur Thousand Euros UH-RWTH University Hospital of the RWTH University VFA visceral fat area1 Muscle wasting and alterations of body composition are linked to clinical outcomes in numerous medical conditions. The role of myosteatosis in posttransplant outcomes remains to be determined. Here we investigated skeletal muscle mass and myosteatosis as prognostic factors in patients undergoing orthotopic liver transplantation (OLT). The data of 225 consecutive OLT recipients from a prospective database were retrospectively analyzed (May 2010-December 2017). Computed tomography-based skeletal-muscleindex (muscle mass), visceral-fat-area (visceral adiposity), and mean skeletal-muscle-radiation-attenuation (myosteatosis) were calculated using a segmentation tool. Cut-off values of myosteatosis resulted in a good stratification of patients into low-and high-risk groups in terms of morbidity (Clavien-Dindo ≥3b). Patients with myosteatosis had significantly higher complication rates (90-day Comprehensive Complication Index 68 ± 32vs 44 ± 30, P < .001) and also displayed significantly longer intensive care (18 ± 25 vs 11 ± 21 days, P < .001) and hospital stay (56 ± 55 vs 33 ± 24 days, P < .001). Estimated costs were 44% higher compared to patients without myosteatosis. Multivariable analysis identified myosteatosis as an independent prognostic factor for major morbidity (odds ratio: 2.772, confidence interval: 1.516-5.066, P = .001). Adding myosteatosis to the well-established Balance-of-Risk-(BAR) score resulted in an increased prognostic value compared to the original BAR score. Myosteatosis may be a useful parameter to predict perioperative outcome in patients undergoing OLT, supporting the role of muscle quality (myosteatosis) over quantity (muscle mass) in this setting. K E Y W O R D Sbody composition, clinical decision-making, clinical research/practice, complication, liver transpla...

Background Myosteatosis is associated with perioperative outcomes in orthotopic liver transplantation (OLT). Here, we investigated the effects of body composition and myosteatosis on long-term graft and patient survival following OLT. Methods Clinical data from 225 consecutive OLT recipients from a prospective database were retrospectively analysed (May 2010 to December 2017). Computed tomography-based lumbar skeletal muscle index (SMI) (muscle mass) and mean skeletal muscle radiation attenuation (SM-RA) (myosteatosis) were calculated using a segmentation tool (3D Slicer). Patients with low skeletal muscle mass (low SMI) and myosteatosis (low SM-RA) were identified using predefined and validated cut-off values. Results The mean donor and recipient age was 55 ± 16 and 54 ± 12 years, respectively. Some 67% of the recipients were male. The probability of graft and patient survival was significantly lower in patients with myosteatosis compared with patients with higher SM-RA values (P = 0.011 and P = 0.001, respectively). Low skeletal muscle mass alone was not associated with graft and patient survival (P = 0.273 and P = 0.278, respectively). Dividing the cohort into quartiles, based on the values of SMI and SM-RA, resulted in significant differences in patient but not in graft survival (P = 0.011). Even though multivariable analysis identified low SM-RA as an important prognostic marker (hazard ratio: 2.260, 95% confidence interval: 1.177-4.340, P = 0.014), myosteatosis lost its significance when early mortality (90 days) was excluded from the final multivariable model. Patients with myosteatosis showed significantly higher all-cause mortality and in particular higher rates of deaths due to respiratory and septic complication (P = 0.002, P = 0.022, and P = 0.049, respectively). Conclusions Preoperative myosteatosis may be an important prognostic marker in patients undergoing deceased donor liver transplantation. The prognostic value of myosteatosis seems to be particularly important in the early post-operative phase. Validation in prospective clinical trials is warranted.

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