Sarco‐Model: A score to predict the dropout risk in the perspective of organ allocation in patients awaiting liver transplantation

Abstract

Background & Aims Sarcopenia in liver transplantation (LT) cirrhotic candidates has been connected with higher dropouts and graft losses after transplant. The study aims to create an ‘urgency’ model combining sarcopenia and Model for End‐stage Liver Disease Sodium (MELDNa) to predict the risk of dropout and identify an appropriate threshold of post‐LT futility. Methods A total of 1087 adult cirrhotic patients were listed for a first LT during January 2012 to December 2018. The study population was split into a training (n = 855) and a validation set (n = 232). Results Using a competing‐risk analysis of cause‐specific hazards, we created the Sarco‐Model2. According to the model, one extra point of MELDNa was added for each 0.5 cm2/m2 reduction of total psoas area (TPA) < 6.0 cm2/m2. At external validation, the Sarco‐Model2 showed the best diagnostic ability for predicting the risk of 3‐month dropout in patients with MELDNa < 20 (area under the curve [AUC] = 0.93; P = .003). Using the net reclassification improvement, 14.3% of dropped‐out patients were correctly reclassified using the Sarco‐Model2. As for the futility threshold, transplanted patients with TPA < 6.0 cm2/m2 and MELDNa 35‐40 (n = 16/833, 1.9%) had the worse results (6‐month graft loss = 25.5%). Conclusions In sarcopenic patients with MELDNa < 20, the ‘urgency’ Sarco‐Model2 should be used to prioritize the list, while MELDNa value should be preferred in patients with MELDNa ≥ 20. The Sarco‐Model2 played a role in more than 30% of the cases in the investigated allocation scenario. In sarcopenic patients with a MELDNa value of 35‐40, ‘futile’ transplantation should be considered.

Body composition and the skeletal muscle compartment in liver transplantation: Turning challenges into opportunities

“…35 This suggest that patients with pathological BC profiles and low MELD might benefit from certain priorization of urgency for LT, eventually expediting LT using extended criteria allografts or living donors to prevent their waiting list dropout. 35 Besides further attempts reported recently by others to combine sarcopenia with MELD, 11,36 It should be noted that due to the current inmaturity of clinical diagnostic criteria in defining relevant pathologies of the SMC, the presence of significant sarcopenia, myosteatosis or sarcopenic obesity should not provide the sole basis to determine candidacy and urgency for LT. 16 Nevertheless, BC assessment provides an excellent platform which can be easily integrated into the clinical decision making as a supporting tool in the identification of patients presenting with an increased malnutritional risk who would benefit from an urgent and intensified pre-LT BC "upstaging approach" in terms of therapeutic interventions and "prehabilitation" programs. 16,35…”

“…35 Besides further attempts reported recently by others to combine sarcopenia with MELD, 11,36 It should be noted that due to the current inmaturity of clinical diagnostic criteria in defining relevant pathologies of the SMC, the presence of significant sarcopenia, myosteatosis or sarcopenic obesity should not provide the sole basis to determine candidacy and urgency for LT. 16 Nevertheless, BC assessment provides an excellent platform which can be easily integrated into the clinical decision making as a supporting tool in the identification of patients presenting with an increased malnutritional risk who would benefit from an urgent and intensified pre-LT BC "upstaging approach" in terms of therapeutic interventions and "prehabilitation" programs. 16,35…”

CONUT Score Predicts Early Morbidity After Liver Transplantation: A Collaborative Study

“…As an example, a recent study from Italy reported that an "urgency" model combining MELDNa and sarcopenia should be used to prioritize the sarcopenic patients with an initial MELDNa <20 on the list, further underlying the relevance of the nutritional status in the LT candidates and the scarce ability of the MELD system in capturing the actual complexity of these patients (38).…”

Sarcopenia Worsening One Month after Transarterial Radioembolization Predicts Progressive Disease in Patients with Advanced Hepatocellular Carcinoma

“…Third, the initial sarcopenic status should consent to select a sub-group of HCC patients receiving TARE as downstaging for liver transplant. Therefore, the sarcopenic status should be of great importance with the intent to “shift” these patients to a potentially curative therapy, consenting to select patients with predictable positive outcomes after transplantation [ 21 ].…”