Body composition predicts mortality and decompensation in compensated cirrhosis patients: A prospective cohort study

Quick and easy assessment of sarcopenia in cirrhosis: Can ultrasound be the solution?

Cirrhosis is frequently associated with sarcopenia, with reported rates of over 80% in patients with decompensated alcohol-related liver disease. Sarcopenia negatively impacts the prognosis of cirrhotic patients and affects the response to treatment of patients with hepatocellular carcinoma (HCC). For these reasons, identifying an easy-to-perform method to assess sarcopenia in is a key element in the optimization of care in this patient population. Assessment of muscle mass by computed tomography is considered the standard of care for the diagnosis of sarcopenia, but exposure to radiation and high costs limit its application in this setting, especially for repeated assessments. We believe that ultrasound, a cheap and harmless technique also used for HCC screening in cirrhotic patients, could have an expanding role in the diagnosis and follow-up of sarcopenia in these patients.

Longitudinal changes in bone mineral density may be associated with long-term survival in patients with cirrhosis: A proof of concept of study

INTRODUCTION

The impact of longitudinal changes in different body components measured via body composition analysis (BCA) on liver-related outcomes in patients with cirrhosis is poorly understood. We evaluated the prognostic relevance of longitudinal changes in body composition over one year in patients with cirrhosis.

METHODS

This was a follow-up study of a randomized controlled trial evaluating changes in bone density measured via dual energy X-ray absorptiometry (DEXA) upon vitamin D supplementation. Patients with available anthropometric indices, fat mass (FM), fat-free mass (FFM), bone-density at lumbar spine (LD) and left femur-neck (FD) (assessed by T score) at two time points one year apart were assessed for outcomes. The prognostic relevance of change in parameters such as ΔFM, ΔFFM, ΔLD and ΔFD over one year was assessed and compared with baseline model for end-stage liver disease (MELD) score.

RESULTS

Patients with cirrhosis (n=112) (mean age 41.8±12 years, 58.5% males) were followed up for median duration of 5.7 years interquartile range [IQR 3.5-5.7], with five-year survival rate of 77%. On serial BCA, ΔLD (p=0.029) and ΔFD (p=0.003) emerged as significant predictors of survival, whereas ΔFM (p=0.479), ΔFFM (p=0.245) and ΔBMI (p=0.949) were not. The area under curve of ΔLD and MELD score for predicting survival was 0.636 (0.5-0.773) and 0.664 (0.555-0.773), respectively. ΔFD<0.1 over one year had sensitivity and specificity of 70.4% and 56.5% to predict poor survival. The combination of ΔFD, MELD and ascites predicted five-year survival with an optimism-corrected c-statistic of 0.785.

CONCLUSION

Among body composition parameters, changes in bone mineral density correlate best with survival and have prognostic relevance similar to that of ascites and MELD score.

Prevalence and effect on prognosis of sarcopenia in patients with primary biliary cholangitis

Background

Sarcopenia adversely affects the treatment outcomes in Cirrhosis and NAFLD. However, such research is limited in primary biliary cholangitis (PBC) patients. This study was performed to examine the prevalence of sarcopenia and its impact on PBC patients' prognoses.

Methods

This study enrolled confirmed PBC patients who had an abdominal CT scan. Sarcopenia was determined by the L3-skeletal muscle index with a Chinese population-based cut-off value. Laboratory test values and liver stiffness measurements values were obtained from the electronic medical records.

Results

In total, 174 PBC patients with a median age of 54 (IQR, 48, 62) years old, were enrolled. 45 (25.9%) patients among them were diagnosed with sarcopenia. Univariate and multivariate logistic regression results illustrated that male gender (OR = 9.152, 95%CI = 3.131-26.751, p < 0.001) and LSM ≥ 12.8 kPa (OR = 4.539, 95%CI = 1.651, 12.478, p = 0.003) were the independent risk factors of sarcopenia in PBC patients. In the prognosis analysis, sarcopenia was determined as a risk factor for indicating adverse events in PBC patients (HR = 4.058, 95%CI = 1.955-8.424, p < 0.001) by Cox proportional hazards regression.

Conclusion

The current findings illustrate that comprehensive evaluation and management of sarcopenia may contribute to the improvement of treatment outcomes and life quality of PBC patients.

Influence of subcutaneous adipose tissue index on prognosis in cirrhotic patients following endoscopic therapy: a retrospective cohort study

BACKGROUND

The relation of adipose tissue depletion with prognostic outcome of variceal bleeding among cirrhotic patients is still inconclusive. The present work explored whether adipose tissue, which was measured based on computed tomography (CT), was valuable for analyzing rebleeding and mortality among patients with variceal bleeding who had undergone endoscopic therapy.

METHODS

The study encompassed cirrhotic patients who underwent endoscopic therapy to prevent variceal rebleeding between January 2016 and October 2022. The L3-level CT images were obtained. Besides, impacts of subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), as well as total adipose tissue index (TATI) on rebleeding and mortality among cirrhotic patients following endoscopic therapy were examined.

RESULTS

In this work, our median follow-up period was 31 months. Among those adipose tissue indexes, only SATI exhibited an independent relation to higher rebleeding (HR 0.981, 95% CI, 0.971-0.991, p < 0.001) and mortality (HR 0.965, 95% CI, 0.944-0.986, p = 0.001) risks. Upon multivariate Cox regression, low SATI (male < 30.15 cm2/m2, female < 39.82 cm2/m2) was independently linked to higher rebleeding risk (HR 2.511, 95% CI, 1.604-3.932, p < 0.001) and increased mortality risk (HR 3.422, 95% CI, 1.489-7.864, p = 0.004) after adjusting for other predictors. Furthermore, subgroups were created based on using nonselective β-blockers (NSBBs), demonstrating that quantitatively assessing SATI exerts a vital role in evaluating rebleeding incidence in patients with or without NSBB therapy.

CONCLUSION

This study underscores the potential of quantifying SATI as a means for achieving a more accurate risk classification for individual patients and identifying patients that can gain more benefits from nutritional intervention.

Incorporation of quantitative imaging data using artificial intelligence improves risk prediction in veterans with liver disease

BACKGROUND AND AIMS

Utilization of electronic health records data to derive predictive indexes such as the electronic Child-Turcotte-Pugh (eCTP) Score can have significant utility in health care delivery. Within the records, CT scans contain phenotypic data which have significant prognostic value. However, data extractions have not traditionally been applied to imaging data. In this study, we used artificial intelligence to automate biomarker extraction from CT scans and examined the value of these features in improving risk prediction in patients with liver disease.

APPROACH AND RESULTS

Using a regional liver disease cohort from the Veterans Health System, we retrieved administrative, laboratory, and clinical data for Veterans who had CT scans performed for any clinical indication between 2008 and 2014. Imaging biomarkers were automatically derived using the analytic morphomics platform. In all, 4614 patients were included. We found that the eCTP Score had a Concordance index of 0.64 for the prediction of overall mortality while the imaging-based model alone or with eCTP Score performed significantly better [Concordance index of 0.72 and 0.73 ( p <0.001)]. For the subset of patients without hepatic decompensation at baseline (n=4452), the Concordance index for predicting future decompensation was 0.67, 0.79, and 0.80 for eCTP Score, imaging alone, or combined, respectively.

CONCLUSIONS

This proof of concept demonstrates that the potential of utilizing automated extraction of imaging features within CT scans either alone or in conjunction with classic health data can improve risk prediction in patients with chronic liver disease.

Coexistence of muscle atrophy and high subcutaneous adipose tissue radiodensity predicts poor prognosis in hepatocellular carcinoma

Introduction

We aimed to assess the prognostic implications of muscle atrophy and high subcutaneous adipose tissue (SAT) radiodensity in patients with hepatocellular carcinoma (HCC).

Methods

In this retrospective study, muscle atrophy was assessed using the psoas muscle index (PMI) obtained from computed tomography. SAT radiodensity was evaluated based on radiodensity measurements. Survival and multivariate analyses were performed to identify factors associated with prognosis. The impact of muscle atrophy and high SAT radiodensity on prognosis was determined through survival analysis.

Results

A total of 201 patients (median age: 71 years; 76.6% male) with HCC were included. Liver cirrhosis was observed in 72.6% of patients, and the predominant Child-Pugh grade was A (77.1%). A total of 33.3% of patients exhibited muscle atrophy based on PMI values, whereas 12.9% had high SAT radiodensity. Kaplan-Meier survival analysis demonstrated that patients with muscle atrophy had significantly poorer prognosis than those without muscle atrophy. Patients with high SAT radiodensity had a significantly worse prognosis than those without it. Muscle atrophy, high SAT radiodensity, the Barcelona Clinic Liver Cancer class B, C, or D, and Child-Pugh score ≥ 6 were significantly associated with overall survival. Further classification of patients into four groups based on the presence or absence of muscle atrophy and high SAT radiodensity revealed that patients with both muscle atrophy and high SAT radiodensity had the poorest prognosis.

Conclusion

Muscle atrophy and high SAT radiodensity are significantly associated with poor prognosis in patients with HCC. Identifying this high-risk subgroup may facilitate the implementation of targeted interventions, including nutritional therapy and exercise, to potentially improve clinical outcomes.

A scoping review of the methods used in patients with liver cirrhosis to assess body composition and their nutritional findings

BACKGROUND AND OBJECTIVES

Body composition (BC) assessment in cirrhosis has a wide variety of methods with no consensus on the best tools for each body component in patients with Liver Cirrhosis (LC). We aimed to conduct a systematic scoping review of the most frequent body composition analysis methods and nutritional findings published in liver cirrhosis patients.

METHODS

We searched for articles in PubMed, Scopus, and ISI Web of Science databases. Keywords selected the BC methods and parameters in LC.

RESULTS

Eleven methods were found. The most frequently used were computed tomography (CT) 47.5%, Bioimpedance Analysis 35%, DXA 32.5%, and anthropometry 32.5%. Up to 15 BC parameters were reported from each method.

CONCLUSIONS

The vast heterogeneity in the results found during the qualitative analysis and imaging methods must reach a consensus to achieve a better clinical practice and improve nutritional treatment, as the physiopathology in LC compromises the nutritional status directly.

Insulin-like growth factor 1 predicts decompensation and long-term prognosis in patients with compensated cirrhosis

AIM

Insulin-like growth factor 1 (IGF-1), which is primarily produced in hepatocytes and is associated with liver functional reserve, plays a crucial role in the pathological condition of cirrhosis. This study aimed to investigate the usefulness of serum IGF-1 levels for predicting the long-term prognosis and decompensation development in patients with cirrhosis.

METHODS

We retrospectively evaluated 148 patients with cirrhosis and divided them into three groups according to baseline IGF-1 levels: low (L)-, intermediate (I)-, and high (H)-IGF-1 groups. The cumulative survival rates were compared among these groups in compensated and decompensated cirrhosis, respectively. Significant and independent factors associated with mortality and decompensation development were identified using Cox proportional hazards regression analysis.

RESULTS

The median observation period was 57.1 (41.7-63.2) months. Thirty (20.3%) patients died of liver disease-related events and 21 (22.3%) patients with compensated cirrhosis developed decompensation. Multivariate analysis identified low serum IGF-1 levels as a significant and independent factor associated with mortality (all patients: hazard ratio [HR], 0.967; p = 0.004; patients with compensated cirrhosis: HR, 0.927; p = 0.002). The cumulative survival rates were significantly lower in the L-IGF-1 group than in the H-IGF-1 and I-IGF-1 groups (all patients: p < 0.001 and = 0.009; patients with compensated cirrhosis: p = 0.012 and 0.003, respectively). However, in decompensated cirrhosis, the cumulative survival rates demonstrated no significant differences among the three groups. The cumulative decompensation incidence rates were significantly higher in the L-IGF-1 group than in the H-IGF-1 and I-IGF-1 groups (p < 0.001 and = 0.009, respectively). Low serum IGF-1 levels were significantly and independently associated with decompensation development (HR, 0.939; p < 0.001).

CONCLUSION

Low serum IGF-1 levels were significantly and independently associated with decompensation development and poor long-term prognosis in patients with compensated cirrhosis. Therefore, IGF-1 may be useful for predicting decompensation-related events and should be regularly monitored in the management of compensated phase.

Visceral adiposity in cirrhosis: Association with disease severity and impact of liver transplantation

BACKGROUND

Changes in adipose tissue distribution in liver cirrhosis are poorly characterized and may affect clinical outcomes.

METHODS

Adult liver transplant (LT) January 2008-August 2017 recipients with abdominal MRI within 6 months pre-LT were retrospectively assessed. Visceral adipose tissue, subcutaneous adipose tissue, and skeletal muscle area (cm2) were determined at L3. Visceral-to-subcutaneous adipose tissue ratio (VSR) was used to define relative adipose distribution, stratified by sex. Correlation was tested with Pearson. Body composition measures were compared by Child-Turcotte-Pugh (CTP) class, before and after LT, and evaluated as predictors of clinical outcomes.

RESULTS

A total of 318 patients were studied. Mean age was 56 years, 33.64% were female, and 47.80% had CTP C cirrhosis. CTP C was associated with a 0.42-point increase in VSR compared with CTP A (95% CI = 0.13-0.71, p < 0.01), adjusting for age, sex, diabetes, and HCC. Among the 79 (24.84%) patients with repeat MRI 1-2 years after LT, VSR significantly improved from before LT (1.31 vs. 0.95, p < 0.01). In adjusted analysis, CTP C was associated with a 0.86-point decrease in post-LT VSR compared with pre-LT VSR (95% CI = -1.27 to -0.44, p < 0.01). Body mass index poorly correlated with VSR before and after LT. Elevated pre-LT VSR trended toward an association with a 7.17-point decrease in pre-LT glomerular filtration rate (95% CI = -14.35 to -0.02, p = 0.05), adjusting for CTP C, age, sex, diabetes, hypertension, pre-LT sarcopenia, and hepatocellular carcinoma. Elevated pre-LT VSR did not affect 3-year post-LT mortality (log-rank p = 0.24).

CONCLUSIONS

Poorly represented by body mass index, visceral adiposity is increased in cirrhosis and is associated with CTP class. However, this adipose redistribution may be modifiable by LT.

Predicting which patients with cirrhosis will develop overt hepatic encephalopathy: Beyond psychometric testing

It remains challenging to identify covert hepatic encephalopathy and predict progression to overt hepatic encephalopathy. Psychometric testing is a widely used diagnostic modality, but it is often inaccurate and difficult to implement in diverse populations, making it a less than ideal assessment. Alternatively, by using easily accessible data from the electronic health record, simple clinical assessment tools, and patient-reported outcomes, we may be better able to predict hepatic encephalopathy across multiple populations. Furthermore, incorporation of patient-reported outcomes into our diagnostic toolset not only aids detection of covert hepatic encephalopathy and prediction of overt hepatic encephalopathy, but also allows us to target therapies and track their impact. Herein, we outline a potential algorithm based on these easily integrated tools to promote patient risk-stratification and early therapeutic intervention.

Sarcopenia in cirrhosis: epidemiology, diagnosis, management and prognosis

PURPOSE OF REVIEW

With the development of many international guidelines, research on sarcopenia has increased rapidly, showing that sarcopenia is predictive of adverse outcomes, including increased mortality and impaired mobility, in patients with cirrhosis. The purpose of this article is to review the current evidence concerning the epidemiology, diagnosis, management and predictive value of sarcopenia on the prognosis of patients with cirrhosis.

RECENT FINDINGS

Sarcopenia is a frequent and lethal complication of cirrhosis. Currently, abdominal computed tomography imaging is the most commonly used method to diagnose sarcopenia. In clinical practice, assessing muscle strength and physical performance, such as by measuring handgrip strength and gait speed, is of increasing interest. In addition to the necessary pharmacological therapy, adequate intake of protein, energy and micronutrients, as well as regular moderate-intensity exercise, can help to minimize sarcopenia. Sarcopenia has been shown to be a strong predictor of prognosis in patients with severe liver disease.

SUMMARY

A global consensus is needed on the definition and operational parameters for the diagnosis of sarcopenia. Further research should focus on developing standardized screening, management and treatment protocols for sarcopenia. Adding sarcopenia to existing models may better exploit the effect of sarcopenia on prognosis in patients with cirrhosis, which should be investigated further.

Osteosarcopenia in NAFLD/MAFLD: An Underappreciated Clinical Problem in Chronic Liver Disease

Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), affects a significant portion of the population worldwide. NAFLD is characterised by fat accumulation in the liver, while NASH is associated with inflammation and liver damage. Osteosarcopenia, which combines muscle and bone mass loss, is an emerging clinical problem in chronic liver disease that is often underappreciated. The reductions in muscle and bone mass share several common pathophysiological pathways; insulin resistance and chronic systemic inflammation are the most crucial predisposing factors and are related to the presence and gravity of NAFLD and to the worsening of the outcome of liver disease. This article explores the relationship between osteosarcopenia and NAFLD/MAFLD, focusing on the diagnosis, prevention and treatment of this condition in patients with CLD.

Low adipose tissue index as an indicator of hepatic encephalopathy in cirrhotic patients following transjugular intrahepatic portosystemic shunt

PURPOSE

We aimed to investigate the predictive value of body compositions measured by CT, including skeletal muscle and adipose tissue, for hepatic encephalopathy (HE) in cirrhotic patients following transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

Patients who underwent TIPS between November 2015 and April 2021 were included in this retrospective study. CT images taken at L3 were quantified for three body composition indexes (cm²/m²), visceral fat area index (VFAI), subcutaneous fat area index (SFAI), and skeletal muscle index (SMI) at baseline. Multivariable logistic regression models were conducted to assess associations between post-TIPS HE and body compositions. Nomograms based on the multivariable logistic regression models were developed and were evaluated from Calibration curves.

RESULTS

Male patients had greater SMI, whereas SFAI and VFAI were higher in females (p < 0.001 for each). In sex stratified multivariate analyses after adjustment for other confounding variables, VFAI in males (p = 0.033) and SFAI in females (p = 0.003) were significant predictors of post-TIPS HE. Male patients with low VFAI (< 53.52 cm²/m²) (OR 6.44; 95% CI 1.72-23.59; p = 0.006) and female patients with low SFAI (< 70.05 cm²/m²) (OR 10.55; 95% CI 2.36-46.23; p = 0.002) had a higher risk of post-TIPS HE. Risk factors in the nomogram contributing to the male model included age, height, Child-Pugh score, and low VFAI; pre-albumin and low SFAI were contributed to female model.

CONCLUSION

Body compositions could not only be noninvasively used for nutritional assessment, but also be utilized to predict HE risk of cirrhotic patients after TIPS.

Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques

BACKGROUND

Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality.

OBJECTIVE

To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients.

METHODS

This retrospective study includes 297 patients 70 years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1 month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU).

RESULTS

For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points.

CONCLUSION

Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling.

CLINICAL IMPACT

Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.

Home-based intensive nutrition therapy improves frailty and sarcopenia in patients with decompensated cirrhosis: A randomized clinical trial

BACKGROUND AND AIM

The majority of patients with decompensated cirrhosis suffer from malnutrition, a potentially modifiable contributor to frailty and sarcopenia. The present study investigated the impact of a 6-month dietician-supported home-based intensive nutrition therapy (HINT) intervention on objective frailty and sarcopenia metrics in patients with decompensated cirrhosis.

METHODS

One hundred adult patients with decompensated cirrhosis, frailty, and sarcopenia at baseline were randomized 1:1 to receive standard medical therapy (SMT) plus HINT (intervention) versus SMT (control) alone. The primary outcome was an improvement in frailty as measured by the liver frailty index (LFI). Secondary outcome measures included sarcopenia metrics, liver disease severity scores, hospitalization, and death.

RESULTS

The LFI improved more in the intervention arm as compared with controls (0.8 vs 0.4; P < 0.001). Baseline and end-of-study skeletal muscle index (SMI) was available in a subset of 32 male patients, with greater improvements seen in the intervention arm compared with controls (6.36 vs 0.80; P = 0.02). Patients in the intervention arm had less hospitalizations over the 6-month follow-up (19 [38%] vs 29 [58%]; P = 0.04). On subgroup analysis, in the 64% of patients who were adherent to calorie and protein intake targets at 6 months, significant improvement was seen in liver disease severity scores and survival (P < 0.05).

CONCLUSION

In patients with decompensated cirrhosis, frailty, and sarcopenia, a 6-month dietitian-supported home-based intensive outpatient nutrition therapy was associated with statistically and clinically relevant improvement in frailty. The subgroup of adherent patients showed improvement in their liver disease scores and reduction in mortality. These findings support the key role of food as medicine in the management of cirrhosis.

Sarcopenia Defined by Psoas Muscle Thickness Predicts Mortality After Transjugular Intrahepatic Portosystemic Shunt

PURPOSE

To assess and compare the value of psoas muscle thickness at the level of the third lumbar (L3) vertebra (TPML) or umbilicus (TPMU) and skeletal muscle index (SMI) for diagnosing sarcopenia and predicting mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS).

MATERIALS AND METHODS

Two hundred forty-nine patients undergoing TIPS were included in this retrospective study. The cut-offs of L3-SMI for sarcopenia were 42.0 cm²/m² in men and 38.0 cm²/m² in women. The cut-offs for TPML/height and TPMU/height to predict mortality was established using a receiver-operating characteristic analysis. The Kaplan-Meier and Cox regression were used for survival analyses.

RESULTS

Compared with TPMU/height, TPML/height was more consistent with L3-SM for the diagnosis of sarcopenia (Kappa coefficient: 0.63 vs. 0.36 in men; 0.61 vs. 0.45 in women). The Cox analysis showed that both TPML/height and TPMU/height were independent risk factors for mortality. The optimal cut-off values of TPML/height and TPMU/height for mortality in men and women were 11.2 mm/m, 9.4 mm/m, 18.4 mm/m, 15.1 mm/m, respectively. There were 119 (47.8%), 87 (34.9%), and 82 (32.9%) patients diagnosed with sarcopenia in the TPMU/height, TPML/height, and L3-SMI models, respectively. Kaplan-Meier analysis showed that the overall survival was significantly lower in the sarcopenia group in all three models.

CONCLUSION

TPMU/height and TPML/height have a similar survival prognostic value as L3-SMI. TPML/height has better consistency with L3-SMI in diagnosing sarcopenia and is a more stable alternative to L3-SMI for diagnosing sarcopenia in patients undergoing TIPS.

Ultrasound Versus Computed Tomography for Diaphragmatic Thickness and Skeletal Muscle Index during Mechanical Ventilation

Background: Diaphragmatic alterations occurring during mechanical ventilation (MV) can be monitored using ultrasound (US). The performance of computed tomography (CT) to evaluate diaphragmatic thickness is limited. Further, the association between muscle mass and outcome is increasingly recognized. However, no data are available on its correlation with diaphragmatic thickness. We aimed to determine correlation and agreement of diaphragmatic thickness between CT and US; and its association with muscle mass and MV parameters. Methods: Prospective observational study. US measurements of the diaphragmatic thickness were collected in patients undergoing MV within 12 h before or after performing a CT scan of the thorax and/or upper abdomen. Data on skeletal muscle index (SMI), baseline, and ventilatory data were recorded and correlated with US and CT measures of diaphragmatic thickness. Agreement was explored between US and CT data. Results: Twenty-nine patients were enrolled and the diaphragm measured by CT resulted overall thicker than US-based measurement of the right hemidiaphragm. The US thickness showed the strongest correlation with the left posterior pillar at CT (r = 0.49, p = 0.008). The duration of the controlled MV was negatively correlated with US thickness (r = -0.45, p = 0.017), the thickness of the right anterior pillar (r = -0.41, p = 0.029), and splenic dome by CT (r = -0.43, p = 0.023). SMI was positively correlated with US diaphragmatic thickness (r = 0.50, p = 0.007) and inversely correlated with the duration of MV before enrollment (r = -0.426, p = 0.027). Conclusions: CT scan of the left posterior pillar can estimate diaphragmatic thickness and is moderately correlated with US measurements. Both techniques show that diaphragm thickness decreases with MV duration. The diaphragmatic thickness by US showed a good correlation with SMI.

Body fat composition determines outcomes before and after liver transplantation in patients with cirrhosis

Cachexia occurs in late stages of liver cirrhosis, and a low-fat mass is potentially associated with poor outcome. This study compared different computed tomography (CT)-derived fat parameters with respect to its prognostic impact on the development of complications and death before and after liver transplantation. Between 2001 and 2014, 612 patients with liver cirrhosis without hepatocellular carcinoma listed for liver transplantation met the inclusion criteria, including abdominal CT scan (±200 days to listing). A total of 109 patients without cirrhosis served as controls. The subcutaneous fat index (SCFI), the paraspinal muscle fat index, and the visceral fat index were assessed at L3/L4 level and normalized to the height (cm² /m² ). Data were collected and analyzed retrospectively. Low SCFI was associated with a higher rate of ascites and increased C-reactive protein levels (p < 0.001). In addition, multivariate Cox regression analysis adjusting for sex, age, body mass index (BMI), and Model for End-Stage Liver Disease showed that decreasing SCFI was also associated with an increased risk of cirrhosis-related complications (p = 0.003) and death on the transplant wait list (p = 0.013). Increased paraspinal and visceral fat were not only positively correlated with creatinine levels (p < 0.001), BMI, and metabolic comorbidities (all p < 0.001) before transplantation, but also predictive for 1-year mortality after transplantation. Conclusion: The distribution of body fat is a major determinant for complications and outcome in cirrhosis before and after liver transplantation.

Higher subcutaneous adipose tissue radiodensity is associated with increased mortality in patients with cirrhosis

Background & Aims

Association between sarcopenia and mortality in cirrhosis is well recognised; however, little is known about the clinical implications of adipose tissue radiodensity, indicative of biological features. This study aimed to determine an association between high subcutaneous adipose tissue (SAT) radiodensity and survival, compare the prevalence of high SAT radiodensity between healthy population and patients with cirrhosis, and identify an association between computed tomography (CT)-measured SAT radiodensity and histological characteristics.

Methods

Adult patients with cirrhosis (n = 786) and healthy donors (n = 129) with CT images taken as part of the liver transplant (LT) assessment were included. Abdominal SAT biopsies (1–2 g) were harvested from the incision site at the time of LT from 12 patients with cirrhosis.

Results

The majority of patients were male (67%) with a mean model for end-stage liver disease (MELD) score of 15 ± 8. SAT radiodensity above -83 HU in females (sub-distribution hazard ratio [sHR] 1.84, 95% CI 1.20–2.85, p = 0.006) and higher than -74 HU in males (sHR 1.51, 95% CI 1.05–1.18, p = 0.02) was associated with the highest mortality risk after adjusting for confounders in competing risk analysis. The frequency of high SAT radiodensity was 26% for those with cirrhosis, compared with 2% in healthy donors (p <0.001). An inverse correlation was found between SAT radiodensity and the mean cross-sectional area of SAT adipocytes (r = -0.67, p = 0.02). Shrunken, smaller adipocytes with expanded interstitial space were predominant in patients with high SAT radiodensity, whereas larger adipocytes with a thin rim of cytoplasm were observed in patients with low SAT radiodensity (744 ± 400 vs. 1,521 ± 1,035 μm², p <0.001).

Conclusion

High SAT radiodensity frequently presents and is associated with a higher mortality in cirrhosis. SAT morphological rearrangement in patients with high SAT radiodensity might indicate diminished lipid stores and alterations in tissue characteristics.

Lay summary

Poor quality of subcutaneous adipose tissue (fat under the skin) is associated with higher mortality in patients with end-stage liver disease. Fat cells are smaller in patients with poor adipose tissue quality.

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Subcutaneous adipose tissue (SAT) radiodensity can be objectively measured by CT in Hounsfield units (HU).

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SAT radiodensity constitutes an indirect surrogate marker of adipose tissue quality.

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High SAT radiodensity in cirrhosis was defined as >-83 HU in females and >-74 HU in males.

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High SAT radiodensity presents in more than a quarter of patients with cirrhosis and is associated with higher mortality.

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High SAT radiodensity might indicate adipose tissue remodelling with morphological features of atrophy.

Systematic review: development of a consensus code set to identify cirrhosis in electronic health records

BACKGROUND

Electronic health records (EHRs) collate longitudinal data that can be used to facilitate large-scale research in patients with cirrhosis. However, there is no consensus code set to define the presence of cirrhosis in EHR. This systematic review aims to evaluate the validity of diagnostic coding in cirrhosis and to synthesise a comprehensive set of ICD-10 codes for future EHR research.

METHOD

MEDLINE and EMBASE databases were searched for studies that used EHR to identify cirrhosis and cirrhosis-related complications. Validated code sets were summarised, and the performance characteristics were extracted. Citation analysis was done to inform development of a consensus code set. This was then validated in a cohort of patients.

RESULTS

One thousand six hundred twenty-six records were screened, and 18 studies were identified. The positive predictive value (PPV) was the most frequently reported statistical estimate and was ≥80% in 17/18 studies. Citation analyses showed continued variation in those used in contemporary research practice. Nine codes were identified as those most frequently used in the literature and these formed the consensus code set. This was validated in diverse patient populations from Europe and North America and showed high PPV (83%-89%) and greater sensitivity for the identification of cirrhosis than the most often used code set in the recent literature.

CONCLUSION

There is variation in code sets used to identify cirrhosis in contemporary research practice. A consensus set has been developed and validated, showing improved performance, and is proposed to align EHR study designs in cirrhosis to facilitate international collaboration and comparisons.

Frailty is associated with increased risk of cirrhosis disease progression and death

BACKGROUND AND AIMS

The Liver Frailty Index (LFI) is a well-studied tool that evaluates frailty in patients with cirrhosis. Consisting of grip strength, chair stands, and balance testing, the LFI has been associated with increased mortality in patients awaiting liver transplant. We aimed to extend our understanding of frailty in cirrhosis by exploring the relationship between the LFI and the risk of (1) cirrhosis progression, (2) mortality, and (3) unplanned hospitalizations, in both compensated and decompensated disease.

APPROACH AND RESULTS

Adult patients with cirrhosis from four centers in North America and one in India were included. Frailty was measured at baseline using the LFI and categorized as robust (LFI < 3.2), prefrail (LFI 3.2-4.5), and frail (LFI > 4.5). Progression of cirrhosis was defined by an increase in clinical stage, ranging from 1 to 5, from baseline using the D'Amico classification. Factors associated with progression, mortality, and hospitalizations were evaluated using multivariate regression models, with transplant as a competing risk. In total, 822 patients with cirrhosis were included. Average Model for End-Stage Liver Disease (MELD) score was 15.5 ± 6.0. In patients with compensated cirrhosis, being frail versus robust was associated with increased risk of progression to the next cirrhosis stage or to death (HR, 2.45; 95% CI, 1.14-5.29) and with an increased risk of unplanned hospitalizations (2.32; 95% CI, 1.13-4.79), after adjusting for age, sex, and MELD score. Similar HRs were observed in patients with decompensated cirrhosis.

CONCLUSIONS

Frailty was an independent predictor of cirrhosis progression or death and unplanned hospitalization across patients with compensated and decompensated cirrhosis. Future studies are needed to evaluate the possibility of slowing cirrhosis disease progression by reversing or preventing frailty.

Healthy US population reference values for CT visceral fat measurements and the impact of IV contrast, HU range, and spinal levels

Measurements of visceral adipose tissue cross-sectional area and radiation attenuation from computed tomography (CT) scans provide useful information about risk and mortality. However, scan protocols vary, encompassing differing vertebra levels and utilizing differing phases of contrast enhancement. Furthermore, fat measurements have been extracted from CT using different Hounsfield Unit (HU) ranges. To our knowledge, there have been no large studies of healthy cohorts that reported reference values for visceral fat area and radiation attenuation at multiple vertebra levels, for different contrast phases, and using different fat HU ranges. Two-phase CT scans from 1,677 healthy, adult kidney donors (age 18–65) between 1999 and 2017, previously studied to determine healthy reference values for skeletal muscle measures, were utilized. Visceral adipose tissue cross-sectional area (VFA) and radiation attenuation (VFRA) measures were quantified using axial slices at T10 through L4 vertebra levels. T-tests were used to compare males and females, while paired t-tests were conducted to determine the effect (magnitude and direction) of (a) contrast enhancement and (b) different fat HU ranges on each fat measure at each vertebra level. We report the means, standard deviations, and effect sizes of contrast enhancement and fat HU range. Male and female VFA and VFRA were significantly different at all vertebra levels in both contrast and non-contrast scans. Peak VFA was observed at L4 in females and L2 in males, while peak VFRA was observed at L1 in both females and males. In general, non-contrast scans showed significantly greater VFA and VFRA compared to contrast scans. The average paired difference due to contrast ranged from 1.6 to − 8% (VFA) and 3.2 to − 3.0% (VFRA) of the non-contrast value. HU range showed much greater differences in VFA and VFRA than contrast. The average paired differences due to HU range ranged from − 5.3 to 22.2% (VFA) and − 5.9 to 13.6% (VFRA) in non-contrast scans, and − 4.4 to 20.2% (VFA) and − 4.1 to 12.6% (VFRA) in contrast scans. The − 190 to − 30 HU range showed the largest differences in both VFA (10.8% to 22.2%) and VFRA (7.6% to 13.6%) compared to the reference range (− 205 to − 51 HU). Incidentally, we found that differences in lung inflation result in very large differences in visceral fat measures, particularly in the thoracic region. We assessed the independent effects of contrast presence and fat HU ranges on visceral fat cross-sectional area and mean radiation attenuation, finding significant differences particularly between different fat HU ranges. These results demonstrate that CT measurements of visceral fat area and radiation attenuation are strongly dependent upon contrast presence, fat HU range, sex, breath cycle, and vertebra level of measurement. We quantified contrast and non-contrast reference values separately for males and females, using different fat HU ranges, for lumbar and thoracic CT visceral fat measures at multiple vertebra levels in a healthy adult US population.

Comparison of Seven Noninvasive Models for Predicting Decompensation and Hospitalization in Patients with Cirrhosis

BACKGROUND/AIM

Patients with cirrhosis have poor outcomes once decompensation occurs; however, we lack adequate predictors of decompensation. To use a national claim database to compare the predictive accuracy of seven models for decompensation and hospitalization in patients with compensated cirrhosis.

METHODS

We defined decompensation as ascites, hepatic encephalopathy, hepato-renal syndrome, and variceal bleeding. Patients without decompensation at the time of cirrhosis diagnosis were enrolled from 2001 to 2015. Patients with hepatitis B and/or C were grouped as viral cirrhosis. We compared the predictive accuracy of models with the AUC (area under the curve) and c-statistic. The cumulative incidence of decompensation and incidence risk ratios of hospitalization were calculated with the Fine-Gray competing risk and negative binomial models, respectively.

RESULTS

A total of 3722 unique patients were enrolled with a mean follow-up time of 524 days. The mean age was 59 (standard deviation 12), and the majority were male (55%) and white (65%). Fifty-three percent of patients had non-viral cirrhosis. Sixteen and 20 percent of patients with non-viral and viral cirrhosis, respectively, developed decompensation (P = 0.589). The FIB-4 model had the highest 3-year AUC (0.73) and overall c-statistic (0.692) in patients with non-viral cirrhosis. The ALBI-FIB-4 model had the best 1-year (AUC = 0.741), 3-year (AUC = 0.754), and overall predictive accuracy (c-statistic = 0.681) in patients with viral cirrhosis. The MELD score had the best predictive power for hospitalization in both non-viral and viral patients.

CONCLUSIONS

FIB-4-based models provide more accurate prediction for decompensation, and the MELD model has the best predictive ability of hospitalization.

Automated Measurements of Body Composition in Abdominal CT Scans Using Artificial Intelligence Can Predict Mortality in Patients With Cirrhosis

Body composition measures derived from already available electronic medical records (computed tomography [CT] scans) can have significant value, but automation of measurements is needed for clinical implementation. We sought to use artificial intelligence to develop an automated method to measure body composition and test the algorithm on a clinical cohort to predict mortality. We constructed a deep learning algorithm using Google's DeepLabv3+ on a cohort of de-identified CT scans (n = 12,067). To test for the accuracy and clinical usefulness of the algorithm, we used a unique cohort of prospectively followed patients with cirrhosis (n = 238) who had CT scans performed. To assess model performance, we used the confusion matrix and calculated the mean accuracy of 0.977 ± 0.02 (0.975 ± 0.018 for the training and test sets, respectively). To assess for spatial overlap, we measured the mean intersection over union and mean boundary contour scores and found excellent overlap between the manual and automated methods with mean scores of 0.954 ± 0.030, 0.987 ± 0.009, and 0.948 ± 0.039 (0.983 ± 0.013 for the training and test set, respectively). Using these automated measurements, we found that body composition features were predictive of mortality in patients with cirrhosis. On multivariate analysis, the addition of body composition measures significantly improved prediction of mortality for patients with cirrhosis over Model for End-Stage Liver Disease alone (P < 0.001). Conclusion: The measurement of body composition can be automated using artificial intelligence and add significant value for incidental CTs performed for other clinical indications. This is proof of concept that this methodology could allow for wider implementation into the clinical arena.

Phase angle by electrical bioimpedance is a predictive factor of hospitalisation, falls and mortality in patients with cirrhosis

The phase angle is a versatile measurement to assess body composition, frailty and prognosis in patients with chronic diseases. In cirrhosis, patients often present alterations in body composition that are related to adverse outcomes. The phase angle could be useful to evaluate prognosis in these patients, but data are scarce. The aim was to analyse the prognostic value of the phase angle to predict clinically relevant events such as hospitalisation, falls, and mortality in patients with cirrhosis. Outpatients with cirrhosis were consecutively included and the phase angle was determined by electrical bioimpedance. Patients were prospectively followed to determine the incidence of hospitalisations, falls, and mortality. One hundred patients were included. Patients with phase angle ≤ 4.6° (n = 31) showed a higher probability of hospitalisation (35% vs 11%, p = 0.003), falls (41% vs 11%, p = 0.001) and mortality (26% vs 3%, p = 0.001) at 2-year follow-up than patients with PA > 4.6° (n = 69). In the multivariable analysis, the phase angle and MELD-Na were independent predictive factors of hospitalisation and mortality. Phase angle was the only predictive factor for falls. In conclusion, the phase angle showed to be a predictive marker for hospitalisation, falls, and mortality in outpatients with cirrhosis.

Sarcopenia and frailty in decompensated cirrhosis

In patients with decompensated cirrhosis, sarcopenia and frailty are prevalent. Although several definitions exist for these terms, in the field of hepatology, sarcopenia has commonly been defined as loss of muscle mass, and frailty has been broadly defined as the phenotypic manifestation of the loss of muscle function. Prompt recognition and accurate assessment of these conditions are critical as they are both strongly associated with morbidity, mortality, poor quality of life and worse post-liver transplant outcomes in patients with cirrhosis. In this review, we describe the complex pathophysiology that underlies the clinical phenotypes of sarcopenia and frailty, their association with decompensation, and provide an overview of tools to assess these conditions in patients with cirrhosis. When available, we highlight data focusing on patients with acutely decompensated cirrhosis, such as inpatients, as this is an area of unmet clinical need. Finally, we discuss management strategies to reverse and/or prevent the development of sarcopenia and frailty, which include adequate nutritional intake of calories and protein, as well as regular exercise of at least moderate intensity, with a mix of aerobic and resistance training. Key knowledge gaps in our understanding of sarcopenia and frailty in decompensated cirrhosis remain, including best methods to measure muscle mass and function in the inpatient setting, racial/ethnic variation in the development and presentation of sarcopenia and frailty, and optimal clinical metrics to assess response to therapeutic interventions that translate into a reduction in adverse outcomes associated with these conditions.

Clinical impact of sarcopenia assessment in patients with liver cirrhosis

Introduction: Sarcopenia is defined as loss of skeletal muscle mass, strength, and function, and it is associated with increased morbidity and mortality in patients with chronic liver disease.Areas covered: The aim of this review is to provide a detailed report on the pathophysiological mechanisms underlying sarcopenia in cirrhotic patients, the several imaging methods available for the assessment of sarcopenia and the clinical studies evaluating the prognostic role of sarcopenia presence in cirrhotic patients.Expert opinion: Sarcopenia pathogenesis is complex and multifaceted, as chronic catabolic conditions, increased energy expenditure, reduced appetite, side effects of multiple therapies, alterations in circulating levels of hormones, low protein synthesis, presence of ascites or portosystemic shunts are all factors contributing to muscle atrophy in cirrhotic patients. Computed tomography scan is the most validated method to evaluate muscle mass and quality. Sarcopenia is associated with a higher rate waitlist mortality, hepatic encephalopathy, and lower quality of life in patients with liver cirrhosis. Future studies should make an effort to unify and validate liver disease-specific cutoffs for the definition of sarcopenia.

Imaging Software-Based Sarcopenia Assessment in Gastroenterology: Evolution and Clinical Meaning

Sarcopenia is gaining attention as a negative prognostic factor in different fields of medicine, including chronic liver failure. However, the assessment of sarcopenia in patients with liver diseases is often neglected due to unawareness of reliable tools and methods and thus is limited to research studies. Cross-sectional imaging is a diffuse diagnostic tool and is commonly performed in patients with chronic liver failure. The last advancements in radiology image analysis using dedicated software allow an easy and standardized method to assess skeletal muscle volume. Several measures can be obtained from cross-sectional imaging analysis to evaluate sarcopenia in patients affected by chronic liver disease. We aimed to review the recent advances in imaging-based sarcopenia assessment, in particular in patients with chronic liver diseases. As a result, we found that the skeletal muscle index (SMI) seems to be a reliable method to assess sarcopenia in cirrhotic patients. Even if further studies are needed to validate proper cut-offs for each clinical endpoint, physicians are invited to consider the assessment of sarcopenia in the work-up of patients with chronic liver disease.

Compensated Cirrhosis and 20 mm Hg: A Point of No Return?

This editorial comments on the findings from the study by Jindal et al. recently published in The American Journal of Gastroenterology. Weaknesses and strengths of the study are presented, and potential therapeutic strategies for compensated cirrhotic patients with an HVPG ≥20 mm Hg are proposed.

Sarcopenia Severity Based on Computed Tomography Image Analysis in Patients with Cirrhosis

Standardized sex-specific cut-offs for sarcopenia in cirrhosis are needed to identify the risk of clinical complications and to discriminate the severity of sarcopenia. We aimed to compare clinical characteristics between patients with cirrhosis categorized according to the severity of sarcopenia. Computed tomography images were taken at the 3rd lumbar vertebra from 603 patients with cirrhosis and 129 adult donors for living liver transplantation. Patients with skeletal muscle index (SMI) two standard deviations (SD) below the sex-specific mean value of young donors (18-40 years old) were categorized as having severe sarcopenia whereas patients with SMI between -1 and -2 SD of the sex-specific young adult mean values were categorized as having sarcopenia. In the cirrhosis group, 408 patients (68%) were male with the mean age of 57 ± 0.4 years, and MELD score of 14 ± 0.4. Patients were divided into three groups: severe-sarcopenic (SMI < 30 cm²/m² in females and <42 cm²/m² in males), sarcopenic (30 ≤ SMI < 37 cm²/m² in females and 42 ≤ SMI < 50 cm²/m² in males) and non-sarcopenic (SMI ≥ 37 cm²/m² in females and ≥50 cm²/m² in males). Patients with cirrhosis and severe sarcopenia had lower muscle radiodensity and higher plasma neutrophil as well as neutrophil to lymphocyte ratio levels than both non- and sarcopenic groups. The frequency of alcohol-induced cirrhosis, refractory ascites, hepatic encephalopathy, CRP > 20 mg/mL, and severe malnutrition was also higher in severe-sarcopenic patients. The interval between sarcopenia and severe sarcopenia may reflect a window of opportunity in which to intervene and mitigate muscle wasting to improve patient outcomes.

Assessment of muscle mass in critically ill patients: role of the sarcopenia index and images studies

PURPOSE OF REVIEW

Sarcopenia is a progressive generalized decline in skeletal muscle mass, strength, and function. This condition is highly prevalent in critically ill patients and is associated with poor outcomes in the ICU. In this review, we describe the use, evidence, and limitations of the most common validated imaging studies used to assess muscle mass in ICU, and we provide an overview of the benefits of using the sarcopenia index [(serum creatinine/serum cystatin C) × 100]) in the ICU.

RECENT FINDINGS

Currently, the determination of muscle mass using anthropometric measurements and serum biomarkers is unreliable. Several new techniques, including a dual-energy X-ray absorptiometry, computed tomography scan, ultrasonography, and bioimpedance analysis, have been studied and validated for the diagnosis and prognosis of sarcopenia in the ICU. However, these techniques are often not accessible for the majority of critically ill patients. The sarcopenia index constitutes an accurate method to diagnose sarcopenia, predict ICU outcomes, and nutritional status in critically ill patients.

SUMMARY

Diagnosis of sarcopenia has substantial implications in ICU patients. Choosing the correct test to identify patients who may need preventive or therapeutic support for this condition will favorably impact ICU outcomes.

Automated Measurements of Muscle Mass Using Deep Learning Can Predict Clinical Outcomes in Patients With Liver Disease

INTRODUCTION

There is increasing recognition of the central role of muscle mass in predicting clinical outcomes in patients with liver disease. Muscle size can be extracted from computed tomography (CT) scans, but clinical implementation will require increased automation. We hypothesize that we can achieve this by using artificial intelligence.

METHODS

Using deep convolutional neural networks, we trained an algorithm on the Reference Analytic Morphomics Population (n = 5,268) and validated the automated methodology in an external cohort of adult kidney donors with a noncontrast CT scan (n = 1,655). To test the clinical usefulness, we examined its ability to predict clinical outcomes in a prospectively followed cohort of patients with clinically diagnosed cirrhosis (n = 254).

RESULTS

Between the manual and automated methodologies, we found excellent inter-rater agreement with an intraclass correlation coefficient of 0.957 (confidence interval 0.953-0.961, P < 0.0001) in the adult kidney donor cohort. The calculated dice similarity coefficient was 0.932 ± 0.042, suggesting excellent spatial overlap between manual and automated methodologies. To assess the clinical usefulness, we examined its ability to predict clinical outcomes in a cirrhosis cohort and found that automated psoas muscle index was independently associated with mortality after adjusting for age, gender, and child's classification (P < 0.001).

DISCUSSION

We demonstrated that deep learning techniques can allow for automation of muscle measurements on clinical CT scans in a diseased cohort. These automated psoas size measurements were predictive of mortality in patients with cirrhosis showing proof of principal that this methodology may allow for wider implementation in the clinical arena.

Review article: prognostic significance of body composition abnormalities in patients with cirrhosis

BACKGROUND

Recent advances in evaluation of body composition show body mass index to be inadequate in differentiating between body compartments in cirrhosis. Given the limitations of body mass index, body composition evaluation using computed tomography has been increasingly used as a non-invasive clinical tool with prognostic value. Another factor influencing prognosis includes sex-specific differences in body composition that are seen in cirrhosis.

AIM

To review current knowledge regarding the frequency and clinical implications of abnormal body composition features in cirrhosis.

METHODS

We searched PubMed database and limited the literature search to full-text papers published in English. Studies using inappropriate landmarks or demarcation of body composition components on computed tomography images were eliminated.

RESULTS

Sarcopenia is a well established factor affecting morbidity and mortality in cirrhosis. Other important body composition components that have been overlooked thus far include subcutaneous adipose tissue and visceral adipose tissue. Female patients with cirrhosis and low subcutaneous adiposity have a higher risk of mortality, whereas male patients with high visceral adiposity have a higher risk of hepatocellular carcinoma and recurrence following liver transplantation. Increased adipose tissue radiodensity has been associated with risk of decompensation and mortality.

CONCLUSIONS

Further evaluation of body composition abnormalities may help with development of targeted therapeutic strategies and improve outcome in patients with cirrhosis. Moreover, recognition of these abnormalities could improve prioritisation for liver transplantation as our current method based solely on liver function might lead to risk misclassification.