Higher Mortality in Pediatric Liver Transplant Candidates With Sarcopenia

Abstract

Little is known about the impact of sarcopenia (reduced muscle mass and function) in pediatric chronic liver disease. We compared psoas muscle surface area (PMSA), measured at the 4th lumbar vertebrae, in children listed for liver transplantation (LT) to that of healthy controls and studied the impact of sarcopenia on transplant‐associated outcomes. The effect of PMSA (raw value and z score) on survival was studied using multivariable proportional hazards, whereas the impact of PMSA on other transplant‐associated outcomes was assessed by multivariable linear or logistic regression. The correlation of PMSA with anthropometric values and markers of disease severity was studied using Spearman’s rank‐order correlation. Mean PMSA was significantly lower in LT candidates (n = 57, 699.4 ± 591.9 mm2 [mean ± SD]) than controls (n = 53, 1052.9 ± 960.7 mm2; P = 0.02). For LT candidates, there was an increased risk of death (either while on the waiting list or following transplantation) with lower PMSA (hazard ratio [HR], 1.6 per 100 mm2 [P = 0.03]; 95% confidence interval [CI], 1.1‐2.8), amounting to a 4.9 times higher risk of death for every 1 unit decrease in PMSA z score (HR, 4.9 [P = 0.05], 95% CI, 1.2‐34.5), adjusting for age and sex. PMSA did not correlate with posttransplant length of intubation, hospital length of stay, or perioperative complications. PMSA also did not correlate with calculated (r = 0.10, P = 0.60) or appealed Model for End‐Stage Liver Disease/Pediatric End‐Stage Liver Disease scores (r = 0.10, P = 0.69). Pediatric LT candidates have a significant reduction in muscle compared with controls. LT candidates with lower PMSA experience significant increases in mortality. As such, sarcopenia may provide a novel indicator of disease severity in children with chronic liver disease.

Utility of Preoperative Computed Tomography–Based Body Metrics in Relation to Postoperative Complications in Pediatric Liver Transplantation Recipients

“…This study aimed to determine the relation between body metrics (PMI and SMI as measurements of sarcopenia, and ScFI as measurement of subcutaneous fat storage) derived from preoperative abdominal CT scans and postoperative short-term clinical outcomes and complications in children with cirrhotic liver disease undergoing LT. While these body metrics are advocated in adults for predicting postoperative outcomes (4,10), in children studies on tPSMA and PMI have shown varying results, and SMI and ScFI have not been previously studied (14)(15)(16)(17).…”

“…A recent study showed that psoas muscle index (PMI), skeletal muscle index (SMI), and fat indices could be reliably determined even in young children (median age 4.6 months) with biliary atresia (13). Recent pediatric studies have also shown potential clinical application for PMI and total psoas muscle surface area (tPMSA), but did not investigate SMI or fat indices (14)(15)(16)(17). In adults undergoing LT, sarcopenia diagnosed by CT-based body metrics is advocated as an independent predictor of higher waiting list and posttransplantation mortality, and higher perioperative complication rates (18,19).…”

Malnutrition in Pediatric Chronic Cholestatic Disease: An Up-to-Date Overview

“…Fragmentary data suggest that the preoperative values are significantly reduced compared with controls, and the values are correlated with moderate to severe postoperative infections and with longer hospital and ICU stays [ 153 ]. A higher re-operation rate and longer hospital stays following transplantation, but not waitlist mortality, were associated with lower PMI [ 154 ] or psoas muscle surface area (PMSA) [ 155 ]. Sarcopenia, evaluated by total psoas muscle area (tPMA) measurements from computed tomography (CT) imaging, was prevalent in patients with pediatric ESLD awaiting LT, highlighting the need for nutritional support before LT and/or after LT in the PICU [ 156 ].…”

Significance of sarcopenia in children with end‐stage liver disease undergoing liver transplantation

“…16,17 In children, sarcopenia has been associated with poorer growth parameters 11 and an increased risk of death before liver transplantation. 18 Post-liver transplant it has been associated with a longer PICU stay. In this edition's study of Low PMI as an Unfavorable Factor in Children with End-stage Liver Disease Undergoing Liver Transplantation (https:// doi.org/10.1111/petr.13996), sarcopenia was not associated with PELD score.…”

“…Sarcopenia, present in about 40% of cirrhotic adults, is associated with increased morbidity (increased risk of encephalopathy, impaired response to infections) and mortality as well as early post‐liver transplant morbidity and possibly mortality 16,17 . In children, sarcopenia has been associated with poorer growth parameters 11 and an increased risk of death before liver transplantation 18 . Post‐liver transplant it has been associated with a longer PICU stay.…”