Sarcopenia in the prognosis of cirrhosis: Going beyond the MELD score

Table 1 Definition and prevalence of sarcopenia in cirrhosis

Ref.	n	Men, n(%)	Unit of measure	Cutoffs for sarcopenia	Prevalence	Predictors of sarcopenia
Cruz et al[60]	234	157 (67)	L3-4 SMI (cm2/m2)	Men: ≤ 52.4 cm2/m2 Women: ≤ 38.5 cm2/m2	70% (men 76%)
DiMartini et al[40]	338	223 (66)	L3-4 SMI (cm2/m2)	Men: ≤ 52.4 cm2/m2 Women: ≤ 38.5 cm2/m2	68% (men 76%, women 51%)	80% prevalence in alcoholic liver disease vs 31%-71% in other diseases 80% prevalence in normal-weight vs 62% in obese
Hanai et al[8]	130	76 (58)	L3 SMI (cm2/m2)	Men: ≤ 52.4 cm2/m2 Women: ≤ 38.5 cm2/m2	68% (men 82%, women 50%)	In the multivariate analysis, only the male gender [OR (95%CI) = 5.65 (1.43-24.23), P = 0.01] and BMI [0.77 (0.66-0.87), P < 0.0001] were independent predictors of sarcopenia
Meza-Junco et al[43]	116	98 (84)	L3 SMI (cm2/m2)	Men BMI ≥ 25 kg/m2: ≤ 53 cm2/m2 BMI < 25 kg/m2: ≤ 43 cm2/m2 Women: ≤ 41 cm2/m2	30% (men 31%, women 28%)	Age was older (61 ± 1 yr vs 57 ± 1 yr, P = 0.001), and the INR was higher (1.4 ± 0.08 vs 1.2 ± 0.03, P = 0.01) in sarcopenic patients than nonsarcopenic patients
Montano-loza et al[10]	112	78 (70)	L3 SMI (cm2/m2)	Men: ≤ 52.4 cm2/m2 Women: ≤ 38.5 cm2/m2	40% (men 50%, women 18%)	Sarcopenia was more frequent in men (50% vs 18%, P < 0.001) and patients with a low BMI (26 ± 0.7 kg/m2vs 29 ± 0.8 kg/m2, P = 0.003)
Montano-loza et al[45]	248	169 (68)	L3 SMI (cm2/m2)	Men BMI ≥ 25 kg/m2: ≤ 53 cm2/m2 BMI < 25 kg/m2: ≤ 43 cm2/m2 Women: ≤ 41 cm2/m2	45% (men 52%, women 30%)	Sarcopenia was more common in men (P = 0.002), patients with ascites (P = 0.02), patients with low BMI (P < 0.001), and patients with higher bilirubin levels (P = 0.05), creatinine levels (P = 0.02), INR ( P = 0.04), CTP scores (P = 0.002), and MELD scores (P = 0.002)
Tandon et al[11]	142	85 (60)	L3 SMI (cm2/m2)	Men: ≤ 52.4 cm2/m2 Women: ≤ 38.5 cm2/m2	41% (men 54%, women 21%)	In a multivariate logistic regression analysis, male sex [OR (95%CI) = 5.91 (2.38-14.6)], CTP class C [vs CTP class A: 15.4 (1.44-165.7)], and a BMI [0.82 (0.74-0.90)] were independent predictors of sarcopenia

Table 2 Clinical impact of sarcopenia on mortality in cirrhosis patients

Ref.	n	Unit of measure	Level of measure	Factors associated with survival (HR, 95%CI)	Survival among sarcopenic and nonsarcopenic patients	Cause of death
Durand et al[7]	562	TPMT/height, mm/m	umbilicus	MELD score (1.2, 1.14-1.27) TPMT/height (0.86, 0.78-0.94) in MELD-era cohort
Hanai et al[8]	130	SMI, cm2/m2	L3 vertebrae	CTP class B (2.39, 1.07-5.95) CTP class C (5.49, 2.11-15.12) BCAA (0.38, 0.19-0.79) Sarcopenia (3.03, 1.42-6.94)	The 1-, 3-, and 5-yr survival rates in patients with sarcopenia and nonsarcopenia were 85% and 97%, 63% and 79%, and 53% and 79%, respectively (P = 0.01)	No significant difference was seen in cause of death between patients with and without sarcopenia
Kim et al[9]	65	PMTH, mm/m	L4 vertebrae	PMTH (0.81, 0.68-0.97)	The median survival was 16 (95%CI: 7-26) mo in patients with PMTH ≤ 14 mm/m The 1- and 2-yr mortality rates in patients with PMTH ≤ 14 mm/m and PMTH > 14 mm/m were 41.6% and 2.6%, and 66.8% and 15.2%, respectively (P < 0.001)
Meza-Junco et al[43]	116	SMI, cm2/m2	L3 vertebrae	Serum Na (0.89, 0.81-0.98) MELD (1.06, 1.01-1.12) CTP (2.39, 1.43-4.01) TNM stage (2.03, 1.45-2.84) Sarcopenia (2.20, 1.21-4.02)	The median survival was 16 ± 6 mo vs 28 ± 3 mo in sarcopenic patients compared to nonsarcopenic (P = 0.003) The 6-mo, and 1-yr survival rates in patients with sarcopenia and nonsarcopenia were 67% and 90%, and 52% and 82%, respectively	No significant difference was seen in the frequency of sepsis-related death between patients with and without sarcopenia (12% vs 4%, P = 0.2)
Montano-Loza et al[10]	112	SMI, cm2/m2	L3 vertebrae	CTP (1.85, 1.02-3.36) MELD (1.08, 1.03-1.14) Sarcopenia (2.21, 1.23-3.95)	Median survival was 19 ± 6 mo vs 34 ± 11 mo in sarcopenia patients compared to nonsarcopenic patients (P = 0.005) The 6-mo and 1-yr survival rates in patients with sarcopenia and nonsarcopenia were 71% and 90%, and 53% and 83%, respectively	The rate of sepsis-related death was significantly higher in sarcopenic patients than nonsarcopenic patients (22% vs 8%, P = 0.02)
Tandon et al[11]	142	SMI, cm2/m2	L3 vertebrae	Age (1.06, 1.01-1.10) MELD (1.13, 1.09-1.19) Sarcopenia (2.36, 1.23-4.53)	The 1-, 2-, and 3-yr survival rates in patients with sarcopenia and nonsarcopenia were 63% and 79%, 51% and 74%, and 51% and 70%, respectively (P = 0.04)	Rates of sepsis-related death: 47% in sarcopenic patients vs 31% in nonsarcopenic patients (P = 0.48)

BCAA: Branched chain amino acid; PMTH: Psoas muscle thickness by height.

Table 3 Impact of pretransplant sarcopenia on outcomes after liver transplantation

Ref.	n	Unit of measure	Level of measure	Impact on the post-transplant survival	Impact on the post-transplant infection	Impact on the length of post-transplant hospitalization
Cruz et al[60]	234	SMI, cm2/m2	L3-4	SMI was significantly associated with survival post-transplantation (HR, 95%CI: 0.97, 0.94-0.99); P = 0.014)
DiMartini et al[40]	338	SMI, cm2/m2	L3-4	Muscle mass was a significant predictor of survival only in men (HR = 0.95, P = 0.01)		Muscle mass predicted ICU stay, total length of stay, and days of intubation
Durand et al[7]	562	TPMT/height, mm/m	umbilicus	MELD-psoas score was not an independent prognostic factor for post-transplant mortality in pre-MELD and MELD-era cohorts
Englesbe et al[41]	163	TPA, mm2	L4	The risk of post-transplantation mortality increased as psoas area decreased (HR = 3.7/1000 mm2 decrease in psoas area; P < 0.0001)
Krell et al[42]	207	TPA, mm2	L4		Pretransplant TPA (HR = 0.38, P < 0.01) was an independent risk factor for developing a serious posttransplant infection
Masuda et al[64]	204	Area of the psoas muscle, cm2	L3	Sarcopenia was an independent prognostic factor for posttransplant mortality (HR = 2.06, P = 0.047)	The rate of postoperative sepsis was higher in sarcopenic patients than in nonsarcopenic patients (17.7% vs 7.4%, P = 0.03)
Montano-Loza et al[45]	248	SMI, cm2/m2	L3	L3 SMI and the presence of sarcopenia were not associated with increased mortality after liver transplantation	Bacterial infections within the first 90 d after liver transplantation were more common in sarcopenic patients than in nonsarcopenic patients (26% vs 15%, P = 0.04)	Sarcopenic patients had longer hospital stays (40 ± 4 d vs 25 ± 3 d, P = 0.005) and longer ICU stays (12 ± 2 d vs 6 ± 1 d, P = 0.001) after liver transplantation than nonsarcopenic patients

ICU: Intensive care unit.