Imaging-based assessment of sarcopenia in liver transplant candidates: A systematic review

Table 1 Summary of study design, participant demographics, and methodological quality (Newcastle-Ottawa scale score) for the 17 studies

Ref.	Study design	Subjects (male/female)	Mean age (years)	Etiology (%)	MELD	Methods for the diagnosis of sarcopenia	Sarcopenia definition/cutoff	Imaging assessment time frame	NOS quality assessment
Woodward et al[22], 2021	Prospective	42 (36:6)	56	62 chronic hepatitis C; 12 ALD; 7 PSC; 19 others	14 ± 5	BIS, Tengvall; US, mid-forearm, mid-upper arm anteriorly, and mid-tight on the dominant side; CT, L3 SMI; DEXA, SMI	Male ≤ 8.50 kg/m2, female ≤ 5.75 kg/m2; male < 48.9 cm2/m2, female < 36.3 cm2/m2; male < 7.26 kg/m2, female < 5.45 kg/m2	Before LT	5
Molwitz et al[23], 2023	Retrospective	152 (109:43)	55 ± 10	35 ALD; 22 viral; 13 AIH; 6 NASH; 7 re-transplantation; 6 ALF; 12 cryptogenic or other	20 (12-30)	CT, L3 SMI, and muscle density	Male < 50 cm2/m2, female < 39 cm2/m2; mean MRA grouped patients, as BMI-based cutoffs may be biased by edema and ascites	Pre-LT, a short-term (11 months) and long-term (56 months) post-transplant follow-up	7
Forsgren et al[24], 2024	Prospective	18 (13:5)	58 ± 9.4	39 HCV; 33 ALD; 22 NASH; 6 HIV	15.3 ± 5.0	MRI, neck-to-knee, FFMV Z-score (AMRA®) and MFI	FFMV Z-score < 25th percentile and MFI > 75th percentile	LT waitlist	7
Carey et al[25], 2017	Retrospective	396 (277:119)	58 (51, 62)	48 HCV; 17 ALD; 12 NASH; 10 AIH/PBC/PSC; 5 HBV; 7 others	15.2 (11.0-20.6)	CT, superior aspect of L3, SMI	Male 50 cm2/m2, female 39 cm2/m2	Within 3 months post-listing	6
Quinlan et al[26], 2023	Prospective	57 (35:22)	55	48.7 ALD; 23 PSC; 10.2 PBC; 12.8 NASH; 5.2 Other	11.0 (5)	US, VL thickness, and quadriceps ACSA; MRI, L3, SMI, ACSA, mid-ACSA, PCSA, IMAT		LT waitlist	6
Golse et al[27], 2017	Retrospective	256 (196:60)	53 ± 10.5	45 ALD; 35 HCV; 7 HBV; 2 NASH; 2 AIH; 6 biliary; 2 others	19.3 ± 10.2	CT, L3/L4, PMA	Male < 1561 mm2, female < 1464 mm2	4 months before LT	7
Bot et al[28], 2023	Retrospective	169 (125:44)	54 ± 10	33.7 ALD; 14.2 cholestatic disease; 20.1 viral hepatitis; 11.8 HCC; 4.1 AIH; 16.0 others	13 ± 6	CT, L3, SMA, SMI, and MA		LT waitlist	7
Sinclair et al[29], 2019	Retrospective	420 (420:0)	55.4 (49.2, 59.4)	28.3 HCC; 24.3 HCV; 12.6 ALD; 10.2 PSC; 6.2 NAFLD; 18.3 others	16 (12-19)	DEXA, ALMI (ALM adjusted by height)	< 7.26 kg/m2	LT waitlist	7
Kappus et al[30], 2020	Retrospective	355 (232:123)	53.7 (12.0)	29 HCV; 3.3 HBV; 29.9 NASH/cryptogenic; 17.7 ALD; 5.1 AIH; 3.9 PBC; 8.7 PSC; 11.8 others	19.4 (8.3)	CT, L3, SMI	Male 50 cm2/m2, female 39 cm2/m2	LT waitlist	7
Lee et al[31], 2021	Retrospective	72 (52:20)	53.2 ± 8.7	72 HBV; 13 HCV; 1 HBV + HCV; 3 ALD; 11 others	21.1 ± 9.0	CT, L3, ΔSMI	Preoperative ΔSMI: ≤ -30% large decrease in skeletal muscle; > -30% small decrease or increase in SMI	1 year pre-LT, pre-LT (within 2 months), and post-LT	7
Kyselova et al[32], 2025	Prospective	134 (74:60)	59.6 (49.2, 65.3)		14 (11-17)	CT, L3, SMI; 31P MRS, gastrocnemius and soleus, βATP/Ptot, and intramyocellular pH	Male 50 cm2/m2, female 39cm2/m2; βATP/Ptot < 0.74; intramyocellular pH > 7.045	Pre- and post-LT (6, 12, and 24 months)	7
Chae et al[33], 2018	Retrospective	408 (286:122)	52.0 ± 9.0	57.6 HBV; 20.1 ALD; 7.6 HCV; 6.4 toxins and drugs; 3.2 AIH; 0.7 HAV; 4.4 cryptogenic	16 ± 1	CT, L3/L4, PMI	PMI change before LT to POD 7 cutoff ≤ 25th quartile/ < 11.7%	1 month before LT	7
Ebadi et al[34], 2018	Retrospective	353 (246:107)	56 ± 9	ESLD	16 ± 8	CT, L3, SMI and PMI	SMI: Male 50 cm2/m2, female 39 cm2/m2; PMI: Male 51cm2/m2, female 43 cm2/m2	3 months of listing	7
Alconchel et al[35], 2020	Retrospective	57 (49:8)	57 (35, 73)	35 HCC; 21 ALD; 26 HCV; 9 ALF (urgent); 6 other cirrhosis; 3 HBV	NA	CT, L3, PMI		1 month before LT	5
Hey et al[36], 2022	Retrospective	469 (338:131)	55.0 (47.4, 59.7)	29 viral hepatitis; 11 ALD	16 (12-20)	DEXA, APLM	Male < 7.26 kg/m2, female < 5.5 kg/m2	LT waitlist	8
van Vugt et al[37], 2018	Retrospective	224 (149:75)	56 (48, 62)	12.5 ALD; 3.1 HBV; 7.1 HCV; 29 PSC/PBC; 33.5 HCC; 0.5 cholangiocarcinoma; 3.1 NASH; 4 cryptogenic; 2.2 AIH; 5 others	16 (11-20)	CT, L3, SMI	Lowest sex-specific quartile	3 months from listing	9
Kuo et al[38], 2019	Retrospective	126 (80:46)	53 (46-59)	31 HCV; 25 ALD; 7 NASH/NAFLD; 13 AIH/PBC/PSC; 10 HBV; 15 others	32 (25-37)	CT, L3, SMI	Male < 48 cm2/m2	Pre-LT	7

MELD: Model for end-stage liver disease; NOS: Newcastle-Ottawa scale; ALD: Alcoholic liver disease; PSC: Primary sclerosing cholangitis; AIH: Autoimmune hepatitis; NASH: Non-alcoholic steatohepatitis; ALF: Acute liver failure; HCV: Hepatitis C virus; HIV: Human Immunodeficiency virus; PBC: Primary biliary cirrhosis; HBV: Hepatitis B virus; HCC: Hepatocellular carcinoma; HAV: Hepatitis A virus; ESLD: End-stage liver disease; NAFLD: Non-alcoholic fatty liver disease; NA: Not available; BIS: Bioelectrical impedance spectroscopy; US: Ultrasound; CT: Computed tomography; L3: Third lumbar vertebra; SMI: Skeletal muscle index; DEXA: Dual-energy X-ray absorptiometry; LT: Liver transplantation; MRA: Muscle radiodensity attenuation; BMI: Body mass index; FFMV Z-score: Fat-free muscle volume Z-score; MFI: Muscle fat infiltration; VL: Vastus lateralis; ACSA: Anatomical cross-sectional area; MRI: Magnetic resonance imaging; mid-ACSA: Mid-point anatomical cross-sectional area; IMAT: Intermuscular adipose tissue; PCSA: Physiological cross-sectional area; L4: Fourth lumbar vertebra; PMA: Psoas muscle area; ALMI: Appendicular lean mass index; ALM: Appendicular lean mass; ΔSMI: Change in skeletal muscle index; ³¹P MRS: Phosporus-31 magnetic resonance spectroscopy; PMI: Psoas muscle index; POD: Postoperative day; APLM: Appendicular lean mass; AMRA: Advanced magnetic resonance analytics; MA: Muscle attenuation; βATP: Beta adenosine triphosphate; Ptot: Total phosphorus metabolites; βATP/Ptot: Ratio of beta ATP to total phosphorus metabolites.