Severe muscle depletion in patients on the liver transplant wait list: Its prevalence and independent prognostic value

Abstract

As detected by cross-sectional imaging, severe muscle depletion, which is termed sarcopenia, holds promise for prognostication in patients with cirrhosis. Our aims were to describe the prevalence and predictors of sarcopenia in patients with cirrhosis listed for liver transplantation (LT) and to determine its independent prognostic significance for the prediction of waiting-list mortality. Adults listed for LT who underwent abdominal computed tomography/magnetic resonance imaging within 6 weeks of activation were retrospectively identified. The exclusions were hepatocellular carcinoma, acute liver failure, prior LT, and listing for multivisceral transplantation or living related LT. Sixty percent of the 142 eligible patients were male, the median age was 53 years, and the median Model for End-Stage Liver Disease (MELD) score at listing was 15. Fortyone percent were sarcopenic; sarcopenia was more prevalent in males versus females (54% versus 21%, P < 0.001) and increased with the Child-Pugh class (10% for class A, 34% for class B, and 54% for class C, P ¼ 0.007). Male sex, the dry-weight body mass index (BMI), and Child-Pugh class C cirrhosis (but not the MELD score) were independent predictors of sarcopenia. Sarcopenia was an independent predictor of mortality (hazard ratio ¼ 2.36, 95% confidence interval ¼ 1.23-4.53) after adjustments for age and MELD scores. In conclusion, sarcopenia is associated with increased waiting-list mortality and is poorly predicted by subjective nutritional assessment tools such as BMI and subjective global assessment. If this is validated in larger studies, the objective assessment of sarcopenia holds promise for prognostication in this patient population. Liver Transpl 18:1209-1216, 2012. V C 2012 AASLD. See Editorial on Page 1136The adoption of the Model for End-Stage Liver Disease (MELD) score for the allocation of deceased donor hepatic grafts has resulted in reductions in waiting-list mortality and the time to liver transplantation (LT). 1,2 Despite these advantages, the MELD score has recognized limitations, 3,4 including inferior performance in predicting mortality in a subgroup of patients with lower MELD scores. [5][6][7] In order to optimize the utility of the MELD score for the prediction of waiting-list mortality in a broader range of patients and to identify those patients at the greatest risk of deterioration,

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

“…From these 28 records, eight studies assessed muscle mass with means other than CT and one study was performed in a population other than patients awaiting or undergoing liver transplantation. The remaining 19 studies, including 3803 patients in partly overlapping cohorts, were included in this systematic review (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30). Cross-referencing yielded no additional records.…”

“…The methods of muscle measurement and sarcopenia definitions that were used are summarized in Table 2. Nine studies reported the cross-sectional muscle area with corresponding skeletal muscle index (12)(13)(14)17,(22)(23)(24)(25)30), whereas the psoas area was reported in eight studies (15,16,18,19,21,(26)(27)(28) and the dorsal muscle group area was reported in one study (20). One study calculated the morphometric age (calculated with total psoas area, psoas density, and abdominal aortic calcifications) (29).…”

“…The mean skeletal muscle index ranged from 43.0 to 54.3 cm²/m² (13,30). The prevalence of sarcopenia was reported in 17 studies (12)(13)(14)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)30) and ranged from 22.2% (30) to nearly 70% (13). The prevalence greatly depended on the definition used.…”

Cachexia: clinical features when inflammation drives malnutrition

“…Cachexia is clinically relevant since it impacts on patients' quality of life, morbidity and mortality (25)(26)(27) . Nevertheless, the assessment of patients' nutritional status does not represent a priority in many clinical settings (28) .…”

“…Cachexia is associated with worse outcome (25)(26)(27) . In order to develop effective therapies, it should be first assessed whether anabolic potential is still exploitable in patients with acute and chronic diseases.…”