Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Jun 18, 2022; 12(6): 120-130
Published online Jun 18, 2022. doi: 10.5500/wjt.v12.i6.120
Reduced upper limb lean mass on dual energy X-ray absorptiometry predicts adverse outcomes in male liver transplant recipients
Penelope Hey, Rudolf Hoermann, Paul Gow, Timothy P Hanrahan, Adam G Testro, Ross Apostolov, Marie Sinclair
Penelope Hey, Paul Gow, Timothy P Hanrahan, Adam G Testro, Ross Apostolov, Marie Sinclair, Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
Penelope Hey, Rudolf Hoermann, Paul Gow, Adam G Testro, Ross Apostolov, Marie Sinclair, Department of Medicine, University of Melbourne, Melbourne 3052, Australia
Author contributions: All authors have contributed to this manuscript and have agreed on the content; Hey P and Sinclair M were involved in the study design; Hey P and Hanrahan TP performed data collection; Hoermann R performed statistical analysis; Hey P, Gow P, Testro AG, Apostolov R and Sinclair M, were involved in data interpretation, drafting and revising the work; and all authors provided approval of the final version to be published.
Institutional review board statement: This study was approved through the Austin Health Human Research Ethics Committee.
Informed consent statement: The informed consent statement was waived.
Conflict-of-interest statement: All authors declare no conflict-of-interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Penelope Hey, FRACP, MBBS, Research Fellow, Staff Physician, Liver Transplant Unit, Austin Health, 145 Studley Road, Heidelberg 3084, Australia.
Received: January 10, 2022
Peer-review started: January 10, 2022
First decision: April 13, 2022
Revised: April 24, 2022
Accepted: May 22, 2022
Article in press: May 22, 2022
Published online: June 18, 2022

Pre-transplant muscle wasting measured by computed tomography has been associated with adverse clinical outcomes after liver transplantation including increased rates of sepsis and hospitalisation days. Upper limb lean mass (LM) measured by dual-energy X-ray absorptiometry (DEXA) was recently identified as a novel predictor of sarcopenia-associated mortality in men waitlisted for transplantation.


To investigate the use of DEXA LM in predicting gender-stratified early post-transplant outcomes.


Liver transplant recipients who underwent pre-transplant DEXA body composition imaging between 2002 and 2017 were included. Endpoints included post-transplant mortality and graft failure, bacterial infections, acute cellular rejection (ACR) and intensive care and total hospital length of stay.


Four hundred and sixty-nine patients met inclusion criteria of which 338 were male (72%). Median age was 55.0 years (interquartile range 47.4, 59.7) and model for end-stage liver disease (MELD) score 16. Median time from assessment to transplantation was 7 mo (3.5, 12). Upper limb LM was inversely associated with bacterial infections at 180 d post-transplant (hazard ratio = 0.42; 95% confidence interval: 0.20-0.89; P = 0.024) in males only. There was a negative correlation between upper limb LM and intensive care (τb = -0.090, P = 0.015) and total hospital length of stay (τb = -0.10, P = 0.0078) in men. In women, neither MELD nor body composition parameters were associated with post-transplant adverse outcomes or increased length of stay. Body composition parameters, MELD and age were not associated with 90-d mortality or graft failure in either gender. There were no significant predictors of early ACR.


Sarcopenia is an independent and potentially modifiable predictor of increased post-transplant bacterial infections and hospital length of stay in men with cirrhosis. DEXA upper limb LM provides a novel measure of muscle wasting that has prognostic value in this cohort. The lack of association in women requires further investigation.

Keywords: Dual-energy X-ray absorptiometry, Sarcopenia, Body composition, Liver transplantation, Survival

Core Tip: Pre-transplant sarcopenia as measured by single-slice computed tomography has prognostic value in predicting outcomes in liver transplant recipients. In this retrospective study, we explore the association of pre-transplant dual-energy X-ray absorptiometry (DEXA) body composition analysis with early post-transplant outcomes. Low upper limb lean mass (LM) was a predictor of 180-d post-transplant bacterial infections and longer hospital and intensive care length of stay in men but not women. Upper limb LM was superior to other measures of LM including appendicular LM in predicting adverse outcomes. There was no association between pre-transplant body composition and post-transplant mortality, graft failure or early acute cellular rejection. In conclusion, pre-transplant sarcopenia is associated with adverse outcomes in men after liver transplantation. Upper limb LM provides a novel measure of muscle mass that is superior to other measures of LM on DEXA in predicting early post-transplant outcomes.