The value of different CT-based methods for diagnosing low muscle mass and predicting mortality in patients with cirrhosis

Impact of Sarcopenia on Post-Liver Transplant Hospitalization: Insights From a South Asian Cohort

BACKGROUND

Sarcopenia's impact on post-liver transplant outcomes remains a subject of debate, with limited data from South Asia on its association with post-liver transplant hospital stays. This study aims to investigate sarcopenia's influence on post-transplant hospitalization duration in South Asians.

METHODS

In this retrospective study, patients with liver cirrhosis who underwent living-donor liver transplantation (LDLT) at Shifa International Hospital in Islamabad, Pakistan, between January 2022 and January 2023 were included. Computed tomography (CT) images were used to assess the skeletal muscle index (SMI). The areas of the psoas, erector spinae, multifidus, quadratus lumborum, rectus abdominis, transverse abdominis, and internal/external oblique muscles were quantified at the level of L3. The data were analyzed using SPSS version 29.0 (IBM).

RESULTS

There was a total of 84 patients. Mean age was 47.4 ± 12.0 years. There were 62 (73.8%) male patients and 22 (26.2%) female patients. Hepatitis C was noted in 36 (42.9%) patients. Twenty-two (26.2%) patients had hepatocellular carcinoma. Sarcopenia was identified in 58 (69.0%) patients. No significant association was observed between sarcopenia and intensive care unit (ICU) or general floor stays. Regression analysis identified pre-transplant model for end-stage liver disease-sodium (MELD-Na) score as the sole significant factor associated with both ICU and total length of stay (P value .002; P value .009).

CONCLUSION

In our population, sarcopenia did not correlate with post-transplant ICU or overall hospital stay. The pre-transplant MELD-Na score emerged as the most influential predictor of length of stay. Therefore, delaying liver transplant procedures based on muscle mass estimations may not be a practical clinical approach for South Asian patients.

Sarcopenia evaluated by EASL/AASLD computed tomography-based criteria predicts mortality in patients with cirrhosis: A systematic review and meta-analysis

Background & Aims

Sarcopenia is associated with increased morbidity and mortality in patients with cirrhosis, but its definition in current literature is very heterogeneous. We performed a systematic review and meta-analysis to assess the association between mortality and sarcopenia evaluated by computed tomography (CT) in patients with cirrhosis, both overall and stratified for the criteria used to define sarcopenia.

Methods

Medline, Embase, Scopus, and Cochrane Library were searched up to January 2023. We included studies assessing sarcopenia presence with CT scans and providing data on the risk of mortality. Adjusted hazard ratios (HRs) and 95% CIs were pooled using a random-effects model.

Results

Thirty-nine studies comprising 12,827 patients were included in the meta-analysis. The summary prevalence of sarcopenia was 44% (95% CI 38-50%). The presence of sarcopenia (any definition) was an independent predictor of mortality with an adjusted HR of 2.07 (95% CI 1.81-2.36), and the result was consistent in all subgroup analyses. The prognostic role of the EASL/AASLD criteria was confirmed for the first time with an HR of 1.86 (95% CI 1.53-2.26) (n = 14 studies). The cut-offs used to define sarcopenia based on psoas muscle parameters varied among studies, thus, a subgroup analysis was not feasible. There was no substantial heterogeneity for the main estimates and no significant risk of publication bias.

Conclusions

Sarcopenia on CT is associated with a 2-fold higher risk of mortality in patients with cirrhosis. The cut-offs proposed by EASL/AASLD are prognostically relevant and should be the recommended criteria used to define sarcopenia in clinical practice.

Impact and implications

Sarcopenia assessed by the reference standard (computed tomography scan) is an independent predictor of mortality in patients with cirrhosis, with a 2-fold increase in the risk of death in all sensitivity analyses. This finding is particularly valid in patients from Europe and North America, and in transplant candidates. Stratifying for the parameters and cut-offs used, we confirmed for the first time the prognostic impact of the definition proposed by EASL/AASLD, supporting their use in clinical practice. Psoas muscle assessment is promising, but data are still limited and too heterogeneous to recommend its routine use at present.

Myosteatosis is an independent risk factor for overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunting

OBJECTIVE

The relationship between skeletal muscle and adipose tissue compositions and risk of overt hepatic encephalopathy (OHE) following transjugular intrahepatic portosystemic shunt (TIPS) treatment needs to be investigated.

METHODS

A total of 282 patients were collected from two medical centres. The median time of follow-up was 48.23 + 1.36 months and the first-year results of all patients after TIPS therapy were collected. The muscle and adipose tissue indices were quantified at the third lumbar vertebra level. Sarcopenia and myosteatosis were defined according to previous researches. Receiver operating characteristic curves, chi-square test, univariate and multivariate logistic regression analyses were employed to investigate the potential association between muscle and adipose indices, sarcopenia, myosteatosis and the risk of developing post-TIPS OHE.

RESULTS

All skeletal muscle indices, adipose tissue indices and sarcopenia had limited associations with post-TIPS OHE. Myosteatosis (148 cases, 52.5%, 55 with OHE, 37.2%) was identified as an independent risk factor for post-TIPS OHE. with P  < 0.001 in Chi-square test, P  < 0.001, odds ratio (OR): 2.854, 95% confidence interval (CI): 1.632-4.993 in univariate logistic regression analyses, and P  = 0.007, OR: 2.372, 95% CI: 1.268-4.438 in multivariate logistic regression analyses, respectively.

CONCLUSION

Our results showed that myosteatosis was proven as an independent risk factor for the development of post-TIPS OHE.

Clinical usefulness of psoas muscle thickness for the prognosis of acute type A aortic dissection patients undergoing total arch replacement

Background

Sarcopenia has emerged as a comprehensive predictor of mortality in diseased populations. The aim of this study was to evaluate the prognostic and predictive value of psoas muscle thickness/height (PMTH) measurement in patients with acute type A aortic dissection (AAAD).

Methods

A retrospective analysis of patients (from January 2020 to December 2020) who underwent AAAD surgery at our institution was conducted. PMTH, as a measure of sarcopenia, was measured by preoperative computed tomography. Patients were classified into two groups according to the cut-off value of PMTH. To balance potential bias, a 1:1 propensity score matching (PSM) with a caliper 0.05 was conducted.

Results

PSM analysis created 68 pairs of patients. In short-term outcomes, a lower PMTH value was strongly correlated with higher in-hospital mortality and renal failure. Receiver operating characteristic (ROC) analysis suggested that sarcopenia had good predictive capabilities in in-hospital mortality, with the area under curve (AUC) of 0.81 [95% confidence interval (CI): 0.64-0.97]. During a median follow-up of 37 months, 24 (19.4%) patients died, including 16 in low PMTH group and 8 in high PMTH group. Kaplan-Meier analysis indicated the sarcopenia significantly affected long-term survival [log-rank P=0.02; hazard ratio (HR) 2.53 (95% CI: 1.13-5.66)]. Multivariable Cox regression analysis revealed that sarcopenia was an independent predictor for decreased survival [HR 2.73 (95% CI: 1.15-8.78)].

Conclusions

Sarcopenia defined from the PMTH may be a useful tool for predicting short- and long-term mortality in patients after AAAD surgery.

Body Compositions Correlate With Overt Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt: A Multicentre Cohort Study

BACKGROUND

The relationship between body composition and the risk of overt hepatic encephalopathy (OHE) following transjugular intrahepatic portosystemic shunt (TIPS) needs to be investigated.

METHODS

Overall, 571 patients from 5 medical centers were included. To assess body compositions, we evaluated skeletal muscle indices, adipose tissue indices, sarcopenia, and myosteatosis at the third lumbar vertebral level. Univariate and Multivariate logistic regression analyses were performed to identify independent risk factors for post-TIPS OHE. An integrated score was then constructed using stepwise multiple regression analyses, with a cut-off value selected using the best Youden index. Finally, the Akaike information criterion (AIC) was performed to compare the integrated score and independent risk factors on their ability in predicting post-TIPS OHE.

RESULTS

Sarcopenia and all skeletal muscle indices had limited associations with post-TIPS OHE. The index of the subcutaneous adipose tissue (SATI) (P=0.005; OR: 1.034, 95% CI: 1.010-1.058) and myosteatosis (297 cases, 52.01%, 125 with OHE, 42.09%; P=0.003; OR: 1.973; 95% CI: 1.262-3.084) were both ascertained as independent risk factors for post-TIPS OHE. The integrated score (ScoreALL=1.5760 + 0.0107 * SATI + 0.8579 * myosteatosis) was established with a cutoff value of -0.935. The akaike information criterion (AIC) of ScoreALL, SATI, and myosteatosis was 655.28, 691.18, and 686.60, respectively.

CONCLUSIONS

SATI and myosteatosis are independent risk factors for post-TIPS OHE. However, the integrated score was more significantly associated with post-TIPS OHE than other skeletal muscle and adipose tissue factors.

Imaging-based diagnosis of sarcopenia for transplant-free survival in primary sclerosing cholangitis

BACKGROUND

Imaging-based assessment of sarcopenia is a well-validated prognostic tool for patients with chronic liver disease. However, little is known about its value in patients with primary sclerosing cholangitis (PSC). This cross-sectional study aimed to investigate the predictive value of the cross-sectional imaging-based skeletal muscle index (SMI) for transplant-free survival (TFS) in patients with PSC.

METHODS

A total of 95 patients with PSC who underwent abdominal cross-sectional imaging between 2008 and 2022 were included in this retrospective study. SMI was measured at the third lumbar vertebra level (L3-SMI). The cut-off values to define sarcopenia were < 50 cm²/m² in male patients and < 39 cm²/m² in female patients. The primary outcome of this study was TFS, which was defined as survival without liver transplantation or death from any cause.

RESULTS

Our study indicates that L3-SMI sarcopenia impairs TFS in patients with PSC (5-year TFS: 33.9% vs. 83.3%, p = 0.001, log-rank test). L3-SMI sarcopenia was independently associated with reduced TFS via multivariate Cox regression analysis (HR = 2.749; p = 0.028). Body mass index reduction > 10% at 12 months, which is used as MELD standard exception (SE) criterion in Eurotransplant (in Germany only until September 2023), was not significantly associated with TFS in the multivariate Cox regression analysis (HR = 1.417; p = 0.330). Substitution of BMI reduction with L3-SMI in the German SE criteria improved the predictive accuracy of TFS compared to the established SE criteria (multivariable Cox regression analysis: HR = 4.007, p < 0.001 vs. HR = 1.691, p = 0.141).

CONCLUSION

Imaging-based diagnosis of sarcopenia via L3-SMI is associated with a low TFS in patients with PSC and may provide additional benefits as a prognostic factor in patient selection for liver transplantation.

Computed tomography-based abdominal sarcopenic indices and bio-impedance analysis-based skeletal muscle mass index in hemodialyzed patients

BACKGROUND AND AIMS

Information about muscle wasting in hemodialyzed patients evaluated using computed tomography (CT) is limited. The present study aimed to examine the relationships between CT-based abdominal sarcopenic indices and bio-impedance analysis (BIA)-based skeletal muscle mass index (SMMI) in these patients.

METHODS

A total of 100 consecutive maintenance hemodialyzed patients who underwent CT and BIA were included. The psoas muscle index (PMI), paraspinous muscle index (PSMI), and abdominal skeletal muscle index (ASMI) were calculated by adjusting each muscle area to the height square. The psoas muscle thickness per height (PMTH) was measured using a single cross-sectional CT image obtained at the level of the third lumbar vertebra. The relationships between these CT-based sarcopenic indices and the BIA-based SMMI were examined. Moreover, the diagnostic values of these CT-based indices for BIA-defined muscle wasting (defined by the sex-specific SMMI: males, <7.0 kg/m2; females, <5.7 kg/m2) were investigated.

RESULTS

The PMI, PMTH, PSMI, and ASMI were significantly correlated with the SMMI (r = 0.678, 0.760, 0.708, and 0.785, respectively; p < 0.0001 for all). Twenty-eight patients with reduced muscle mass determined by BIA were identified. After age-sex adjustment, a multivariate logistic regression analysis revealed that the C-statistics of the PMI, PMTH, PSMI, and ASMI for the diagnosis of low muscle mass were 0.863 (p = 0.0099), 0.870 (p = 0.013), 0.891 (p = 0.040), and 0.950 (reference), respectively.

CONCLUSIONS

CT-based abdominal sarcopenic indices presented here may be useful for evaluating muscle wasting in hemodialyzed patients; the ASMI may be the most recommended sarcopenic index for such evaluations.

A Prospective Study of Prevalence and Impact of Sarcopenia on Short-term Mortality in Hospitalized Patients with Liver Cirrhosis

Background

Sarcopenia is common in chronic advanced liver disease and is associated with poor prognosis. There is paucity of Indian data regarding sarcopenia in chronic advanced liver disease & its impact on prognosis. The aim of this study was to study the prevalence of sarcopenia in Indian patients with chronic advanced liver disease and its impact on morbidity and short-term mortality.

Methods

Patients with chronic advanced liver disease were prospectively evaluated for the presence of sarcopenia using computerized tomography (CT) abdomen. The cross-sectional area of the right psoas muscle was measured at the third lumbar vertebra (L3) and the Psoas muscle index (PMI) was calculated. Sarcopenia was defined as PMI <295 mm2/m2 for females and <356 mm2/m2 for males. The normative values of PMI were obtained from patients undergoing CT scan for non-specific abdominal pain who had no confounding factor which could result in sarcopenia. All patients were followed up for 6 months or until death, whichever was earlier. The impact of sarcopenia on mortality and rate of readmission has been assessed at the end of 6 months.

Results

Of the 156 patients with chronic advanced liver disease, 74 (47.4%) patients had sarcopenia. Sarcopenia was more commonly seen in males (M: F = 61:13) and in patients with alcohol-related liver disease. There was a linear correlation (negative) between the PMI and severity of liver disease as assessed by Child-Pugh and model for end-stage liver disease (MELD) scores (r = -0.591 and -0.465, respectively). Patients with encephalopathy, ascites, and coagulopathy had higher prevalence of sarcopenia. On six months follow-up, sarcopenic patients had higher readmission rates (74.3% vs. 22%; P = 0.0001) and higher mortality (24.3% vs. 3.7%; P = 0.002). MELD score and PMI were independent predictors of mortality. The cut-off value of PMI 305.9 mm2/m2 predicted mortality with a sensitivity of 76.2% and a false positivity of 22.2% (area under curve was 0.805; 95% confidence interval: 0.69-0.91, P = 0.001).

Conclusion

Sarcopenia is seen in about half of the patients with chronic advanced liver disease. It is commoner in males, patients with alcoholic liver disease, and those with advanced liver disease. Patients with sarcopenia have worse prognosis, require more frequent hospitalization and it negatively impacts short-term survival.

Transversal psoas muscle thickness measurement is associated with response and survival in patients with HCC undergoing immunotherapy

BACKGROUND

Sarcopenia is a common problem in patients with HCC. We aimed to evaluate the prognostic and predictive value of baseline transversal psoas muscle thickness (TPMT) measurement in patients with HCC undergoing immunotherapy.

METHODS

HCC patients treated with programmed death ligand 1-based therapies between June 2016 and October 2022 at the Vienna General Hospital (n = 80) and the Hôpital Beaujon Clichy (n = 96) were included and followed until April 2023. TPMT at the level of the third lumbar vertebra was measured independently by 2 radiologists to evaluate interreader reliability. TPMT <12 mm/m in men and <8 mm/m in women indicated sarcopenia.

RESULTS

Overall, 176 patients (age: 66.3±11.7 y; male: n=143, 81%, Barcelona-Clinic Liver Cancer C: n=121, 69%) were included, of which 131 (74%) exhibited cirrhosis. Interreader agreement for the diagnosis of sarcopenia based on TPMT was 92.6%, and Cohen κ showed a "strong agreement" [κ = 0.84 (95% CI: 0.75-0.92)]. Sarcopenia, present in 58 patients (33%), was associated with shorter median overall survival [7.2 (95% CI: 5.0-9.5) vs. 22.6 (95% CI: 16.4-28.8 months); p < 0.001] and median progression-free survival [3.4 (95% CI: 0.2-6.8) vs. 7.9 (95% CI: 5.8-9.9 months), p = 0.001], and an independent predictor of overall [adjusted HR: 1.63 (95% CI: 1.07-2.48)] and progression-free mortality [adjusted HR: 1.54 (95% CI: 1.06-2.23)] in multivariable analyses. The objective response rate [evaluable in 162 subjects (92.0%)] per modified Response Evaluation Criteria In Solid Tumors (mRECIST) in patients with and without sarcopenia was 22% and 39%, respectively (p = 0.029). Survival and radiological responses were worse in patients with sarcopenia and systemic inflammation [median overall survival: 6.1 (95% CI: 3.6-8.6) mo; median progression-free survival: 2.8 (95% CI: 2.1-3.4) mo; objective response rate=16%; disease control rate=39%].

CONCLUSIONS

Evaluation of sarcopenia using TPMT measurement is reliable and identifies HCC patients with a dismal prognosis and response to immunotherapy.

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.

Liver transplantation in the patient with physical frailty

Frailty is a decline in functional reserve across multiple physiological systems. A key component of frailty is sarcopenia, which denotes a loss of skeletal muscle mass and impaired contractile function that ultimately result in physical frailty. Physical frailty/sarcopenia are frequent and contribute to adverse clinical outcomes before and after liver transplantation. Frailty indices, including the liver frailty index, focus on contractile dysfunction (physical frailty), while cross-sectional image analysis of muscle area is the most accepted and reproducible measure to define sarcopenia. Thus, physical frailty and sarcopenia are interrelated. The prevalence of physical frailty/sarcopenia is high in liver transplant candidates and these conditions have been shown to adversely impact clinical outcomes including mortality, hospitalisations, infections, and cost of care both before and after transplantation. Data on the prevalence of frailty/sarcopenia and their sex- and age-dependent impact on outcomes are not consistent in patients on the liver transplant waitlist. Physical frailty and sarcopenic obesity are frequent in the obese patient with cirrhosis, and adversely affect outcomes after liver transplantation. Nutritional interventions and physical activity remain the mainstay of management before and after transplantation, despite limited data from large scale trials. In addition to physical frailty, there is recognition that a global evaluation including a multidisciplinary approach to other components of frailty (e.g., cognition, emotional, psychosocial) also need to be addressed in patients on the transplant waitlist. Recent advances in our understanding of the underlying mechanisms of sarcopenia and contractile dysfunction have helped identify novel therapeutic targets.

Contributory roles of sarcopenia and myosteatosis in development of overt hepatic encephalopathy and mortality after transjugular intrahepatic portosystemic shunt

BACKGROUND

Skeletal muscle abnormalities, such as muscle mass depletion (sarcopenia) and fatty infiltration of the muscle (myosteatosis), are frequent complications in cirrhotic patients scheduled for transjugular intrahepatic portosystemic shunt (TIPS).

AIM

To investigate the association and predictive value of sarcopenia and myosteatosis for overt hepatic encephalopathy (HE) and mortality after TIPS.

METHODS

The records of cirrhotic patients who underwent the TIPS procedure at our hospital between January 2020 and June 2021 were retrospectively retrieved. The transversal psoas muscle thickness (TPMT) and psoas muscle attenuation (PMA) measured from the unenhanced abdominal computed tomography (CT) at the level of the third lumbar vertebrae were used to analyze the sarcopenia and myosteatosis, respectively. The area under curve (AUC) was used to evaluate the discriminative power of TPMT, PMA, and relevant clinical parameters. Fur-thermore, log-rank test was performed to compare the incidence of overt HE and survival between the different groups, and the association of risk factors with overt HE and mortality was analyzed using Cox proportional hazards regression models.

RESULTS

A total of 108 patients were collected. Among these patients, 45.4% of patients developed overt HE after TIPS treatment. Furthermore, 32.4% and 28.7% of these patients were identified to have myosteatosis and sarcopenia, respectively. Myosteatosis (51.0% vs 16.9%, P < 0.001) and sarcopenia (40.8 vs 18.6%, P = 0.011) were found to be more frequent in patients with overt HE, when compared to patients without overt HE. The receiver operating characteristics analysis indicated that the predictive power of TPMT and PMA in overt HE (AUC = 0.713 and 0.778, respectively) was higher when compared to the neutrophil lymphocyte ratio (AUC = 0.636). The cumulative incidence of overt HE was the highest in patients with concomitant sarcopenia and myosteatosis, followed by patients with myosteatosis or sarcopenia, while this was the lowest in patients without sarcopenia and myosteatosis. In addition, sarcopenia and myosteatosis were inde-pendently associated with overt HE and mortality after adjusting for confounding factors in post-TIPS patients.

CONCLUSION

CT-based estimations for sarcopenia and myosteatosis can be used as reliable predictors for the risk of developing overt HE and mortality in cirrhotic patients after TIPS.

Prevalence and prognosis of Computed-Tomography defined sarcopenia in Tunisian cirrhotic patients

INTRODUCTION

Sarcopenia is an underdiagnosed and understudied complication of cirrhosis, especially in patients not undergoing liver transplantation.

AIM

To evaluate the prevalence and prognostic impact of radiological sarcopenia in non-transplanted cirrhotic patients.

METHODS

Longitudinal retrospective study including cirrhotic patients explored by an abdominal CT scan, over a period of 6 years, in a single gastroenterology department in Tunisia. Sarcopenia was defined according to transversal psoas muscle thickness normalized to height (TPMT/h) in the sagittal CT slice. Two groups were defined: Group 1 with sarcopenia (TPMT/h <16.8mm/m); and Group 2 without sarcopenia (TPMT/h ≥16.8mm/m).

RESULTS

Seventy patients were included (mean age=62 years). The mean MELD score was 12.81 and the mean TPMT/h of 13.56 mm/m. Forty-four patients were sarcopenic (63%). When included, the 2 groups' baseline characteristics were comparable except for women predominance and refractory ascites in group 1. After an average of 21-month follow-up, sarcopenia was associated with a higher number of complications per patient (p=0.013) and a longer average hospital stay duration per patient (p=0.001). Overall survival was significantly decreased in sarcopenic patients (p=0.035). Survival rates at 6 months, 1 year, and 2 years were respectively 42%, 30%, and 24% in Group 1 versus 67%, 40%, and 27% in Group 2. Sarcopenia was an independent factor of mortality in multivariate analysis (OR=2.5; 95% IC [1.02-6.16]; p=0.045).

CONCLUSION

Sarcopenia is frequent and an independent poor prognostic factor in cirrhosis. TPMT/h is an easy and often available method for sarcopenia diagnosis.

Usefulness of the Measurement of Psoas Muscle Volume for Sarcopenia Diagnosis in Patients with Liver Disease

Computed tomography (CT) is often used in the diagnosis of sarcopenia. In this study, we validated the assessment of sarcopenia by the psoas muscle volume using versatile software. The study involved a retrospective analysis of data from 190 patients with liver disease who underwent grip-strength testing and abdominal pelvic computed tomography. To assess sarcopenia, SYNAPSE 3D was used to obtain the skeletal muscle index, the psoas muscle index (PMI), and the simple method. We also used the recently proposed PMI cutoff values, for which the usefulness has been evaluated (O-PMI). The cutoff value of the psoas muscle volume index (PMVI) was determined using one of the diagnostic methods as the gold standard. All diagnostic methods showed that patients with sarcopenia had shorter survival, with O-PMI having the highest hazard ratio (HR) (HR, 6.12; 95% confidence interval [CI], 2.6–14.41; p < 0.001). Even when sarcopenia could not be diagnosed by O-PMI, low PMVI was associated with shorter survival (HR, 3.53; 95% CI, 1.34–9.32; p = 0.01). PMVI may be useful in the evaluation of sarcopenia, including the identification of poor overall survival in cases that cannot be diagnosed by O-PMI, which is considered more useful than PMI.

Preoperative Psoas Muscle Thickness to Height Ratio Predicts Poor Survival After Resection of Biliary Tract Cancer

BACKGROUND/AIM

Accumulating evidence suggests that muscle mass depletion (sarcopenia) has a negative impact on survival in several malignancies, including biliary tract cancer (BTC). Computed tomography (CT)-measured psoas muscle thickness to height ratio (PMTH) has been reported as a surrogate measure for muscle mass that does not require specialized equipment or software. The aim of this retrospective study was to investigate whether preoperative PMTH predicts oncological outcomes of patients undergoing surgical resection for BTC.

PATIENTS AND METHODS

PMTH was assessed in 211 patients by analyzing axial CT images at the level of the umbilicus. The most predictive cutoff of PMTH was determined by survival classification and regression tree analysis. Propensity score-based inverse probability weighting (IPW) was used to balance characteristics between the low and high PMTH groups.

RESULTS

Applying a PMTH cutoff of 17.5 mm/m, the low PMTH group comprised 114 patients (54%). Low PMTH was associated with female sex, non-obesity, CA19-9 elevation, and lymph node metastasis. After IPW adjustment, the low PMTH group had a significantly shorter disease-specific survival (p<0.001) and relapse-free survival (p<0.001) than the high PMTH group. IPW-adjusted regression analysis revealed that a low PMTH was independently associated with worse disease-specific survival (hazard ratio=2.98, p<0.001) and relapse-free survival (hazard ratio=2.49, p<0.001), in addition to other factors such as tumor differentiation, perineural invasion, and resection margin status.

CONCLUSION

Preoperative PMTH may be a simple and feasible index of sarcopenia for predicting poor survival after resection of BTC.

Association between Abdominal CT Measurements of Body Composition before Deceased Donor Liver Transplant with Posttransplant Outcomes

Background Pre-liver transplant (LT) sarcopenia is associated with poor survival. Methods exist for measuring body composition with use of CT scans; however, it is unclear which components best predict post-LT outcomes. Purpose To quantify the association between abdominal CT-based body composition measurements and post-LT mortality in a large North American cohort. Materials and Methods This was a retrospective cohort of adult first-time deceased-donor LT recipients from 2009 to 2018 who underwent pre-LT abdominal CT scans, including at the L3 vertebral level, at Johns Hopkins Hospital. Measurements included sarcopenia (skeletal muscle index [SMI] <50 in men and <39 in women), sarcopenic obesity, myosteatosis (skeletal muscle CT attenuation <41 mean HU for body mass index [BMI] <25 and <33 mean HU for BMI ≥25), visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and VAT/SAT ratio. Covariates in the adjusted models were selected with use of least absolute shrinkage and selection operator regression with lambda chosen by means of 10-fold cross-validation. Cox proportional hazards models were used to quantify associations with post-LT mortality. Model discrimination was quantified using the Harrell C-statistic. Results A total of 454 recipients (median age, 57 years [IQR, 50-62 years]; 294 men) were evaluated. In the adjusted model, pre-LT sarcopenia was associated with a higher hazard ratio (HR) of post-LT mortality (HR, 1.6 [95% CI: 1.1, 2.4]; C-statistic, 0.64; P = .02). SMI was significantly negatively associated with survival after adjustment for covariates. There was no evidence that myosteatosis was associated with mortality (HR, 1.3 [95% CI: 0.86, 2.1]; C-statistic, 0.64; P = .21). There was no evidence that BMI (HR, 1.2 [95% CI: 0.95, 1.4]), VAT (HR, 1.0 [95% CI: 0.98, 1.1]), SAT (HR, 1.0 [95% CI: 0.97, 1.0]), and VAT/SAT ratio (HR, 1.1 [95% CI: 0.90, 1.4]) were associated with mortality (P = .15-.77). Conclusions Sarcopenia, as assessed on routine pre-liver transplant (LT) abdominal CT scans, was the only factor significantly associated with post-LT mortality. © RSNA, 2022 See also the editorial by Ruehm in this issue.

Differences in nutritional risk assessment between NRS2002, RFH-NPT and LDUST in cirrhotic patients

Nutritional status is an independent predictor of outcome in cirrhosis patients. Nutritional Risk Screening 2002 (NRS2002), Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT), and Liver Disease Undernutrition Screening Tool (LDUST) were employed to detect cirrhosis with malnutrition risk in this work. Meanwhile, their diagnostic performances were compared to find the best screening method. This work aimed to establish the sarcopenia cut-off value of the transversal psoas thickness index (TPTI), and identify the risk factors for malnutrition. Cirrhosis patients who were admitted to Heibei Gerneral hospital from April 2021 to October 2021 and underwent abdominal CT examination were enrolled. 78 patients were assessed by NRS2002, RFH-NPT, and LDUST. The Global Leadership Initiative for Malnutrition (GLIM) criteria were selected as the gold standard for the diagnosis of malnutrition. Meanwhile the cut-off value of sarcopenia was established based on the TPTI of malnourished patients. Logistic regression analysis was adopted to assess the influencing factors of malnutrition risk and malnutrition. The prevalence of malnutrition was 42.31%. The prevalence of malnutrition risk was 32.1%, 61.5%, and 62.8% with NRS2002, RFH-NPT, and LDUST, respectively. NRS2002 presented the best specificity compared with the other methods, while RFH-NPT showed the highest sensitivity. The optimal gender-specific TPTI cut-off value for diagnosing sarcopenia was determined as TPTI < 14.56 mm/m (male) and TPTI < 8.34 mm/m (female). In the multivariate analysis, ascites was associated with malnutrition risk, while sarcopenia showed a significant risk for malnutrition. NRS2002 and RFH-NPT were superior to LDUST at detecting the malnutrition in cirrhosis patients diagnosed according to GLIM criteria. The gender-specific TPTI cut-off value was TPTI < 14.56 mm/m (male) and TPTI < 8.34 mm/m (female). Malnutrition risk should be screened for patients with ascites as soon as possible. In addition, it was important to evaluate malnutrition in sarcopenia patients in time.

Measurement of mid-arm circumference as a starting point for nutritional assessment of patients with decompensated cirrhosis: A prospective cohort study

BACKGROUND

The mid-arm circumference (MAC) is an accessible, quick, and inexpensive measurement, which can be performed at the bedside only with a measuring tape. In this sense, the present study aims to suggest MAC cut-off values to assess the nutritional status and its association with mortality of hospitalised patients with decompensated cirrhosis.

METHODS

A prospective cohort study was performed with decompensated cirrhotic patients. Nutritional status was assessed by MAC and Subjective Global Assessment (SGA). Considering the SGA as the reference standard and based on receiver operating characteristic curve analysis, the MAC cut-off values with the best sensitivity and specificity were selected. Predictors of mortality were identified using multivariate analysis.

RESULTS

The study included 100 patients with a mean ± SD age of 60.1 ± 10.3 years. The median follow-up time was 11.2 months and overall mortality was 60%. Considering malnutrition assessed by SGA as the reference standard, the area under the curve of MAC for women and men was 0.947 (95% confidence interval [CI] = 0.878-1.000) and 0.813 (95% CI = 0.694-0.932). The MAC cut-off values of ≤ 28 cm for women and ≤ 30 cm for men reached a sensitivity and specificity of 85.5% and 71%, respectively. According to multivariate analysis, a low MAC was significantly associated with mortality (hazard ratio = 2.41; 95% CI = 1.20-4.84).

CONCLUSIONS

The MAC cut-off values had satisfactory accuracy for men and women in predicting malnutrition. Additionally, a low MAC was an independent predictor of mortality. Thus, these MAC cut-off values can be used as the first step of nutritional assessment to prioritise patients who require more detailed assessment.

Robotic Esophagectomy Compared With Open Esophagectomy Reduces Sarcopenia within the First Postoperative Year: A Propensity Score-Matched Analysis

INTRODUCTION

Sarcopenia is a known risk factor for adverse outcomes after esophageal cancer (EC) surgery. Robot-assisted minimally invasive esophagectomy (RAMIE) offers numerous advantages, including reduced morbidity and mortality. However, no evidence exists to date comparing the development of sarcopenia after RAMIE and open esophagectomy (OE). The objective was to evaluate whether the development of sarcopenia within the first postoperative year after esophagectomy is associated with the surgical approach: RAMIE versus OE.

METHODS

A total of 168 patients with EC were analyzed who either underwent total robotic or fully open Ivor Lewis esophagectomy in a propensity score-matched analysis. Sarcopenia was assessed using the skeletal muscle index (cm²/m²) and psoas muscle thickness per height (mm/m) on axial computed tomography scans during the first postoperative year; in total 540 computed tomography scans were evaluated.

RESULTS

After 1-to-1 propensity score matching for confounders, 67 patients were allocated to RAMIE and OE groups, respectively. Skeletal muscle index in the OE group was significantly lower compared with the RAMIE group at the third (43.2 ± 7.6 cm²/m² versus 49.1 ± 6.9 cm²/m², p = 0.001), sixth (42.7 ± 7.8 cm²/m² versus 51.5 ± 8.2 cm²/m², p < 0.001) and ninth (43.0 ± 7.0 cm²/m² versus 49.9 ± 6.6 cm²/m², p = 0.015) postoperative month. Similar results were recorded for psoas muscle thickness per height.

CONCLUSIONS

To our knowledge, this study is the first to suggest a substantial benefit of RAMIE compared with open esophagectomy in terms of postoperative sarcopenia. These results add further evidence to support the implementation of the robotic approach in multimodal therapy of EC.

Sex is a major effect modifier between body composition and mortality in patients with cirrhosis assessed for liver transplantation

BACKGROUND AND AIMS

Body composition predicts mortality in patients with cirrhosis. The impact of sex on this association is unknown. We investigated the impact of sex on this association in patients with cirrhosis assessed for liver transplantation.

METHODS

This single-centre retrospective cohort study included adults assessed for liver transplantation. Nutritional status was assessed using the Royal Free Hospital-Global Assessment (RFH-GA). Body composition at the third lumbar vertebrae was determined. SarcopeniaSMI was defined as Skeletal Muscle Index <50 cm2 /m2 in males and <39 cm2 /m2 in females. SarcopeniaPMI was defined as the sex-specific 25th percentile of the Psoas Muscle Index. Patients were assessed for the occurrence of liver transplantation and death. Analyses were stratified by sex.

RESULTS

The cohort comprised 628 patients, including 199 females and 429 males. Both groups were similar in terms of baseline liver disease severity by Model for End-stage Liver Disease (MELD) (p = .98) and nutritional status (p = .24). SarcopeniaSMI was present in 41% of males compared to 27% of females (p < .001). In the male cohort, when adjusted for age and MELD, sarcopeniaPMI (aHR 1.74, 95% CI 1.08-2.80) and RFH-GA (aHR 1.40, 95% CI 1.03-1.90) remained independent predictors of mortality. Adipose tissue had no impact on outcomes in males. In female patients, adipose tissue (TATI or VATI depending on the multivariable model) was independently associated with mortality, whereas sarcopenia and malnutrition were not.

CONCLUSIONS

This study demonstrates that male patients were susceptible to low muscle mass, whereas female patients were not. Future research in this patient population should minimize sex-related bias and present data for both groups separately.

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.

"Sarcopenia is associated with increased risk of burst abdomen after emergency midline laparotomy: a matched case-control study"

PURPOSE

Burst abdomen is a serious complication commonly observed after emergency midline laparotomy. Sarcopenia has been associated with increased morbidity and mortality after abdominal surgery. This single-center, retrospective, matched case-control study aimed to investigate the association between sarcopenia and burst abdomen in patients undergoing emergency midline laparotomy.

METHODS

Patients who had burst abdomen after emergency midline laparotomy were matched 1:4 with controls based on age and sex. Abdominal wall closure was standardized in the study period with the small bites, small stitches technique. CT assessed psoas cross-sectional area was used as a surrogate measure of sarcopenia. Sarcopenia was defined as the sex-specific lowest quartile of psoas cross-sectional area adjusted for body surface area. The primary outcome was the incidence rate of sarcopenia amongst cases and controls. Secondary outcomes were risk factors for burst abdomen and death that were identified using multivariate logistic regression analysis.

RESULTS

67 cases were matched to 268 controls during May 2016-December 2019. BMI > 30 kg/m², liver cirrhosis, smoking, high ASA score and peritonitis were more frequently observed among cases. Multivariate analysis revealed that sarcopenia (odds ratio (OR) 2.3, p = 0.01), active smoking (OR 2.3, p = 0.006) and liver cirrhosis (OR 3.7, p = 0.042) were significantly associated with burst abdomen. ASA score ≥ 3 (OR 5.5, p = 0.001) and ongoing malignant disease (OR 3.2, p = 0.001) were significantly associated with increased 90-day mortality.

CONCLUSION

Sarcopenia is associated with increased risk of burst abdomen after midline laparotomy. Prospective trials are needed.

L3 Skeletal Muscle Index Dynamics in Patients with HCV-Related Compensated Cirrhosis Following Sustained Virological Response after Direct Acting Antiviral Treatment

Background and Objectives: Sarcopenia is commonly associated with liver cirrhosis and predicts clinical outcome. Our aim was to identify the changes in skeletal muscle index (SMI) on computed tomography (CT) examination, as a quantitative marker of sarcopenia, in patients with HCV-related cirrhosis after direct acting antivirals (DAAs) treatment and to assess predictive factors for the evolution of SMI. Materials and Methods: This is a single center retrospective study in patients with HCV-related compensated cirrhosis who obtained sustained virological response (SVR) after DAAs. CT examinations were performed in 52 patients before and within 5-24 months after treatment. The total muscle area (TMA) of abdominal muscle at the level of third lumbar vertebra (L3) was measured at baseline and after SVR. The L3-SMI was calculated from TMA divided by body height squared (cm²/m²). We assessed changes in L3-SMI after SVR according to baseline body mass index (BMI) and laboratory data. Predictive factors were assessed by linear regression model. Results: Patients with L3-SMI above the gender-specific cut-off value at baseline had higher values of serum creatinine (median 0.73) compared to patients with low L3-SMI (median 0.68, p = 0.031). After SVR, 14 patients showed increase of L3-SMI, and 38 patients had a decrease of L3-SMI. BMI in the decreased L3-SMI group was significantly lower (median 26.17) than those without decreased L3-SMI (median 28.84, p = 0.021). ALT values in the decreased L3-SMI group (median 66.5) were significantly lower than those without a decrease in L3-SMI (median 88, p = 0.045). Conclusions: Low creatinine serum level correlates with sarcopenia. SMI was partially influenced by the viral clearance. Lower BMI and ALT serum levels at baseline were predictive for no benefit in terms of muscle mass dynamics. Understanding all the mechanisms involved in sarcopenia and identifying the most vulnerable patients could ensure optimal adapted care strategies.

Clinical and biomarker assessment of frailty in liver transplantation

PURPOSE OF REVIEW

Liver cirrhosis results in progressive decline, or frailty, which leads to poor outcomes and decreased survival. Multiple biomarkers and clinical assessment tools for quantifying frailty in liver transplant candidates exist, but a universal scoring protocol is lacking. Criteria vary between studies and correlation with patient outcome is not always clear. This review aims to summarize the pertinent biomarkers and assessment tools of frailty in cirrhosis.

RECENT FINDINGS

As cirrhosis progresses, the resultant 'frailty' is an inseparable independent predictor of pre and posttransplant mortality. Pro-inflammatory, neuroendocrine, and adipokine factors are dysregulated - leading to paradoxical anorexia and downregulation of orexigenic signals. The resulting catabolic utilization of amino and fatty acids leads to progressive malnutrition and sarcopenia. Both functional and imaging criteria define sarcopenia in cirrhotic patients, and degree of debilitation correlates with mortality. Liver-disease-specific frailty biomarkers and scoring tools are optimal to assess physical dysfunction in cirrhotics to promote early diagnosis and intervention.

SUMMARY

Liver cirrhosis and resulting frailty are progressive and portend a poor patient prognosis. A comprehensive, validated algorithm for detecting and quantifying frailty specific to liver disease would allow for standardization and facile application in the clinical setting. Early diagnosis is key for timely intervention and improved patient outcomes.

Usefulness of computed tomography-measured psoas muscle thickness per height for predicting mortality in patients undergoing hemodialysis

Computed tomography (CT)-measured psoas muscle thickness standardized for height (PMTH) has emerged as a promising predictor of mortality. The study aimed to investigate whether PMTH could accurately predict mortality in patients undergoing hemodialysis. We examined 207 patients (mean age: 63.1 years; men: 66.2%) undergoing hemodialysis for more than 6 months in hospital affiliated clinic. PMTH was calculated at the L3 vertebra level using CT. Patients were divided according to the PMTH cut-off points: 8.44 mm/m in women and 8.85 mm/m in men; thereafter, they were combined into low and high PMTH groups. PMTH was independently correlated with the simplified creatinine index (β = 0.213, P = 0.021) and geriatric nutritional risk index (β = 0.295, P < 0.0001) in multivariate regression analysis. During a median follow-up of 3.7 (1.8–6.4) years, 76 patients died, including 41 from cardiovascular causes. In the multivariate Cox regression analysis, low PMTH (adjusted hazard ratio, 2.48; 95% confidence interval, 1.36–4.70) was independently associated with an increased risk of all-cause mortality. The addition of binary PMTH groups to the baseline risk model tended to improve net reclassification improvement (0.460, p = 0.060). In conclusion, PMTH may be an indicator of protein energy wasting and a useful tool for predicting mortality in patients undergoing hemodialysis.

Validation of the Clinical Frailty Scale for the Prediction of Mortality in Patients With Liver Cirrhosis

INTRODUCTION:

Frailty is a common but often underestimated complication in patients with liver cirrhosis. The Clinical Frailty Scale (CFS) allows the assessment of frailty within a short period of time but has only been investigated in a Canadian cohort of outpatients. The aim of the current study was to evaluate the ability of the CFS to predict mortality in outpatients and nonelectively hospitalized German patients.

METHODS:

Two hundred outpatients and 99 nonelectively hospitalized patients with liver cirrhosis were prospectively enrolled. Outpatients/inpatients were followed for a median of 364/28 days regarding the primary outcome of death or liver transplantation. Eighty-seven patients of the outpatient cohort and 64 patients of the inpatient cohort had available computed tomography-scans for the quantification of muscle mass.

RESULTS:

Median CFS was 3 in the outpatient and the inpatient cohort. Twenty-one (10.5%) outpatients were at least prefrail (CFS > 3) and 26 (26.3%) inpatients were frail (CFS > 4). For every one-unit increase, there was an independent association between the CFS and mortality in the outpatient cohort (hazard ratio 1.534, P = 0.007). This association remained significant after controlling for muscle mass in the subcohort with available computed tomography scans. In the inpatient cohort, frailty (CFS > 4) was an independent predictor for 28-day mortality after controlling for acute-on-chronic liver failure, albumin, and infections (odds ratio 4.627, P = 0.045). However, this association did not reach significance in a subcohort after controlling for muscle mass.

DISCUSSION:

Especially in outpatients, CFS is a useful predictor regarding increased mortality independent of the muscle mass.

Muscular abnormalities in liver cirrhosis

Sarcopenia is becoming a well-established player in evaluating patients with chronic liver disease. Data regarding its clinical significance and consequences in the course of liver disease have been growing; many of the data support the idea that it impacts decompensation event frequency, prolonged hospitalization, and mortality, as well as providing the possibility to better prioritize patients on lists awaiting liver transplantation. When assessing the whole clinical scope of the field, which includes malnutrition and frailty, as well as the complete spectrum of muscle mass, strength, and function, it becomes clear that a well-founded approach in everyday clinical practice is essential. In this respect, this article attempts to unveil the most recently published data regarding possible methods and modalities that could be used to diagnose sarcopenia as early as possible, along with the required accuracy and reliability. From the most important field discoveries to data that need further clarification, the merits and weaknesses of the very diverse existing evaluation methods are presented. Finally, a critical overview is given, in an attempt to discern study lines of importance from those that could pose further ambiguity for the theme. The author also poses relevant questions that remain unanswered but are of clinical importance in the field.

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.

Definition of Sarcopenia in Chronic Liver Disease

Sarcopenia, which is characterized by decline in muscle mass, muscle strength, and physical performance, is common in patients with chronic liver disease (CLD) and is associated with poor clinical outcomes. Several consensus definitions for community-dwelling elderly people have been proposed, and these recommend the use of various tools and tests to assess muscle properties and performance. These measurement tools have also been applied in patients with CLD and have been useful for predicting prognosis. However, sarcopenia and its diagnostic criteria specific to patients with CLD have not yet been clearly defined. In addition, fluid retention and body composition should be considered when sarcopenia is assessed in patients with CLD. This review aims to introduce definitions of sarcopenia and diagnostic tools used in patients with CLD.

Prognostic impact of sarcopenia in cirrhotic patients stratified by different severity of portal hypertension

BACKGROUND AND AIMS

Portal hypertension (PH) and sarcopenia are common in patients with advanced chronic liver disease (ACLD). However, the interaction between PH and sarcopenia and their specific and independent impact on prognosis and mortality has yet to be systematically investigated in patients with ACLD.

METHODS

Consecutive patients with ACLD and hepatic venous pressure gradient (HVPG) ≥10 mm Hg with available CT/MRI imaging were included. Sarcopenia was defined by transversal psoas muscle thickness (TPMT) at <12 mm/m in men and <8 mm/m in women at the level of the third lumbar vertebrae. Hepatic decompensation and mortality was recorded during follow-up.

RESULTS

Among 203 patients (68% male, age: 55 ± 11, model for end-stage liver disease [MELD]: 12 [9-15]), sarcopenia was observed in 77 (37.9%) and HVPG was ≥20 mm Hg in 98 (48.3%). There was no correlation between TPMT and HVPG (r = .031, P = .66), median HVPG was not different between patients with vs without sarcopenia (P = .211). Sarcopenia was significantly associated with first/further decompensation both in compensated (SHR: 3.05, P = .041) and in decompensated patients (SHR: 1.86, P = .021). Furthermore, sarcopenia (SARC) was a significant predictor of mortality irrespective of HVPG (HVPG < 20-SARC: SHR: 2.25, P = .021; HVPG ≥ 20-SARC: SHR: 3.33, P = .001). On multivariate analysis adjusted for age, HVPG and MELD, sarcopenia was an independent risk factor for mortality (aHR: 1.99, 95% confidence interval: 1.2-3.3, P = .007).

CONCLUSION

Sarcopenia has a major impact on clinical outcomes both in compensated and in decompensated ACLD patients. The presence of sarcopenia doubled the risk for mortality independently from the severity of PH.

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.

Routine abdominal magnetic resonance imaging can determine psoas muscle area in paediatric Crohn's disease and correlates with bioelectrical impedance spectroscopy measures of lean mass

BACKGROUND

Paediatric Crohn's disease (CD) has been associated with undernutrition. Accurate and accessible measures of body composition would provide data to personalise nutritional therapy. We assessed feasibility of MRI-derived measures of psoas cross-sectional area (PCSA) in paediatric CD and correlated with anthropometric and bioelectrical impedance spectroscopy (BIS) measures.

METHODS

MRI small bowel/pelvis images of patients with CD, aged <18 years, were retrieved. Patients with concurrent anthropometric and BIS measurements were eligible for inclusion. The PCSA at L3 was calculated by two assessors and combined. To assess reproducibility of measures we calculated the coefficient of variation (CoV). Age, height-Z-scores, weight-Z-scores and BIS measures were correlated with PCSA. Using normal paediatric data from CT-scans we derived psoas area Z-scores for our cohort.

RESULTS

10 patients were included. Mean age at MRI scan was 14.6 years (11.7-16.3). PCSA was calculated for all MRI scans. There was high reproducibility between measurers, mean CoV 0.099. There was a significant positive correlation between PCSA and BIA-derived fat free mass, Pearson correlation coefficient (PCC) 0.831, p = 0.003. Correlation coefficients for PCSA and Height-for-age Z-score, weight-for-age -Z-score and age were PCC 0.343- p = 0.33, PCC = 0.222- p = 0.54, and PCC 0.6034- p = 0.065, respectively. The mean PCSA Z-score was -1.81, with 70% of the patients having a Z-score < -2.0.

CONCLUSIONS

These data demonstrate the feasibility of deriving measures of body composition from routine MRI imagine. There was significant positive correlation between PCSA and BIS-derived lean mass. Further studies are required to confirm applicability of normal ranges prior to routine clinical implementation.

Obesity Management of Liver Transplant Waitlist Candidates and Recipients

Obesity is increasing in prevalence in liver transplant candidates and recipients. The rise in liver transplantation for nonalcoholic steatohepatitis reflects this increase. Management of obesity in liver transplant candidates can be challenging due to the presence of decompensated cirrhosis and sarcopenia. Obesity may increase peritransplant morbidity but does not have an impact on long-term post-transplant survival. Bariatric surgery may be a feasible option in select patients before, during, or after liver transplantation. Use of weight loss drugs and/or endoscopic therapies for obesity management ultimately may play a role in liver transplant patients, but more research is needed to determine safety.

Cut-off values of skeletal muscle index and psoas muscle index at L3 vertebra level by computerized tomography to assess low muscle mass

BACKGROUND & AIMS

Computerized tomography (CT) is considered the gold standard for the evaluation of total skeletal muscle quantity. Skeletal muscle assessments at the L3 vertebra level revealed significantly correlated with total body muscle measurements. Clinicians need cut-offs to evaluate low muscle mass in various patients who already had CT imaging without any additional cost. This assessment is important to help the physicians to stratify the patients for mortality and other complications. It may also enable the diagnosis of malnutrition by the GLIM criteria. Few studies reported cut-offs in different populations. We aimed to provide cut-off values for total skeletal muscle index (SMI) and psoas muscle mass index (PMI) at the L3 vertebra level in the Turkish population.

METHODS

We assessed the preoperative plain CT images of living adult liver donors who were admitted to a single transplantation center between June 2010 and April 2018. We derived cut-off values with two alternative methods, the 5th percentile value or mean minus two standard deviations and from two groups of study participants, i.e. the total study population and the younger subgroup aged between 18 and 40.

RESULTS

The study population involved 601 subjects with a mean age of 32.5 ± 9 (range: 18-59 years) and 326 (54.2%) was male. The younger subgroup was composed of 482 individuals with a mean age of 28.8 ± 5.9 and 55.6% male. In patients aged between 18 and 40, PMI and SMI cut-offs by using the 5th percentile were 5.40 cm²/m², 41.42 cm²/m² for males; and 3.56 cm²/m², 30.70 cm²/m² for females; respectively. The cut-offs of PMI and SMI by using mean minus two standard deviations were 4.62 cm²/m², 38.67 cm²/m² for males; and 2.66 cm²/m², 27.8 cm²/m² for females; respectively. These cut-offs were comparable to the other populations.

CONCLUSIONS

Our study provided cut-offs to be used in CT images for PMI and SMI. There is a need for further longitudinal studies to verify whether these cut-offs are successful in predicting mortality or other adverse outcomes associated with low muscle mass.

Radiologic Definition of Sarcopenia in Chronic Liver Disease

Sarcopenia is prevalent in patients with chronic liver disease, and affected patients tend to have worse clinical outcomes and higher mortality. However, relevant analyses are limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing it. We reviewed several radiologic methods for sarcopenia in patients with chronic liver disease. Dual energy X-ray absorptiometry (DXA) can measure muscle mass, but it is difficult to evaluate muscle quality using this technique. Computed tomography, known as the gold standard for diagnosing sarcopenia, enables the objective measurement of muscle quantity and quality. The third lumbar skeletal muscle index (L3 SMI) more accurately predicted the mortality of subjects than the psoas muscle index (PMI). Few studies have evaluated the sarcopenia of chronic liver disease using ultrasonography and magnetic resonance imaging, and more studies are needed. Unification of the measurement method and cut-off value would facilitate a more systematic and universal prognosis evaluation in patients with chronic liver disease.

Radiologic Definition of Sarcopenia in Chronic Liver Disease

Sarcopenia is prevalent in patients with chronic liver disease, and affected patients tend to have worse clinical outcomes and higher mortality. However, relevant analyses are limited by heterogeneity in the definition of sarcopenia and in the methodological approaches in assessing it. We reviewed several radiologic methods for sarcopenia in patients with chronic liver disease. Dual energy X-ray absorptiometry (DXA) can measure muscle mass, but it is difficult to evaluate muscle quality using this technique. Computed tomography, known as the gold standard for diagnosing sarcopenia, enables the objective measurement of muscle quantity and quality. The third lumbar skeletal muscle index (L3 SMI) more accurately predicted the mortality of subjects than the psoas muscle index (PMI). Few studies have evaluated the sarcopenia of chronic liver disease using ultrasonography and magnetic resonance imaging, and more studies are needed. Unification of the measurement method and cut-off value would facilitate a more systematic and universal prognosis evaluation in patients with chronic liver disease.

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.

Skeletal Muscle Index as a Prognostic Marker for Kidney Transplantation in Older Patients

OBJECTIVE

Low skeletal muscle mass has emerged as a risk factor for mortality after liver transplantation. We evaluated the prognostic value of muscle mass on length of hospitalization and adverse outcomes after kidney transplantation in aging end-stage renal disease patients.

METHODS

One hundred twenty-two patients aged 60 years or older at the time of transplantation were retrospectively analyzed. Skeletal muscle index (SMI), evaluated by computed tomography scan, was calculated from total muscle surface area at L3 vertebral level divided by body height squared. Outcomes were compared according to SMI (namely, length of hospitalization, wound complications, combined endpoint comprising all-cause mortality, and graft failure within 1 year).

RESULTS

In male patients, by multivariate analysis, a low SMI (<42 cm²/m²) was associated with longer immediate post-transplantation hospitalization (β = 17.03 ± 4.3; P = .0002), longer total hospitalization during the first year (β = 34.3 ± 10.7; P = .002), higher rate of wound complications (odds ratio = 12.1 [1.9-77.0]; P = .008), and higher rate of the combined endpoint of graft loss or death (odds ratio = 3.4 [3.0-399.5]; P = .004). In female patients, low SMI was not associated with length of hospitalization or adverse outcomes after transplantation.

CONCLUSION

SMI is an independent marker of morbidity and mortality after kidney transplantation in older men and could help thereby nephrologists better select aging candidates for kidney transplantation with a view to improving post-transplant outcomes.

MRI-defined sarcopenia predicts mortality in patients with chronic liver disease

BACKGROUND & AIMS

To explore whether sarcopenia, diagnosed by an abbreviated magnetic resonance imaging (MRI) protocol is a risk factor for hepatic decompensation and mortality in patients with chronic liver disease (CLD).

METHODS

In this retrospective single-centre study we included 265 patients (164 men, mean age 54 ± 16 years) with CLD who had undergone MRI of the liver between 2010 and 2015. Transverse psoas muscle thickness (TPMT) was measured on unenhanced and contrast-enhanced T1-weighted and T2-weighted axial images. Sarcopenia was defined by height-adjusted and gender-specific cut-offs in women as TPMT < 8 mm/m and in men as TPMT < 12 mm/m respectively. Patients were further stratified into three prognostic stages according to the absence of advanced fibrosis (FIB-4 < 1.45, non-advanced CLD), compensated-advanced CLD (cACLD) and decompensated-advanced CLD (dACLD).

RESULTS

The inter-observer agreement for the TPMT measurements (κ = 0.98; 95% confidence interval [95% CI]:0.96-0.98), as well as the intra-observer agreement between the three image sequences (κ = 0.99; 95% CI: 0.99-1.00) were excellent. Sarcopenia was not predictive of first or further hepatic decompensation. In patients with cACLD and dACLD, sarcopenia was a risk factor for mortality (cACLD: hazard ratio (HR):3.13, 95% CI: 1.33-7.41, P = .009; dACLD:HR:2.45, 95% CI: 1.32-4.57, P = .005) on univariate analysis. After adjusting for the model of end-stage liver disease (MELD) score, albumin and evidence of clinical significant portal hypertension, sarcopenia (adjusted HR: 2.76, 95% CI: 1.02-7.42, P = .045) remained an independent risk factor for mortality in patients with cACLD.

CONCLUSION

Sarcopenia can be easily evaluated by a short MRI exam without the need for contrast injection. Sarcopenia is a risk factor for mortality, especially in patients with cACLD.

Use of Skeletal Muscle Index as a Predictor of Wait-List Mortality in Patients With End-Stage Liver Disease

The aim of this study is to validate a proposed definition of sarcopenia in predicting wait-list mortality. We retrospectively evaluated 355 adults (age ≥18 years) with cirrhosis listed for first-time LT from January 1, 2010, to April 1, 2018 from our center. Demographic, laboratory, and outcome data were collected in conjunction with computed tomography scans performed within 3 months of listing. Using imaging analysis software, the skeletal muscle index (SMI), which is a marker for sarcopenia-related mortality, was calculated. A survival analysis was performed to evaluate the association of the proposed sarcopenia definition of SMI <50 cm² /m² for men or <39 cm² /m² for women with wait-list mortality or delisting. Median SMI was 54.1 cm² /m² (range, 47-60 cm² /m² ). A total of 61 (17.2%) patients exhibited sarcopenia according to the proposed threshold, and 24.6% (57/232) of men were sarcopenic compared with 3.3% (4/123) of women (P < 0.001). Mean (standard deviation [SD]) SMI was also higher for men (56.6 ± 9.6 cm² /m² ) than for women (50.7 ± 8.0 cm² /m² ; P < 0.001). Median follow-up time among patients was 2.1 months (0-12 months), and 30 events were observed (hazard ratio, 0.98; 95% confidence interval, 0.95-1.02; P = 0.41). There was no statistically significant difference in time on the waiting list between patients with and without sarcopenia (P = 0.89) as defined at the threshold. Using the prespecified definitions of sarcopenia based on SMI, there was no statistically significant difference in mortality and delisting from the transplant waiting list between patients with and without sarcopenia in this population. Practice and region-specific patterns for pretransplant selection and median Model for End-Stage Liver Disease at transplant may affect SMI as a predictor of wait-list mortality.

Anemia and iron deficiency in compensated and decompensated cirrhosis: Prevalence and impact on clinical outcomes

BACKGROUND AND AIM

Iron deficiency anemia (IDA)is the leading cause of anemia worldwide. Data on prevalence and clinical impact of anemia in cirrhosis are scarce. Aim was to report on the following:(i) prevalence of anemia and IDA in cirrhosis and (ii) its possible impact on clinical outcomes.

METHODS

Consecutive cirrhotic patients from a prospective registry study were included. Anemia was defined as hemoglobin concentration ≤ 12 g/dL. IDA was defined as Hb ≤ 12 g/dL + transferrin-saturation < 20%. Follow up for hepatic decompensation and mortality started with study inclusion and terminated in December 2017. A retrospective validation cohort of 1244 patients was used to validate our findings.

RESULTS

Two hundred forty-two patients with compensated (n = 53 [21.9%]) and decompensated (n = 189 [78.1%]) cirrhosis were included. Anemia was present in 128 patients (52.9%); of those, 63 (49.2%) had IDA. Prevalence of anemia increased with Child-Pugh Score (CPS; A: 26.5%, B: 59.2%, C: 69%; P < 0.001) and with decompensated cirrhosis(62.4% vs 18.8%, P < 0.001). Within anemic patients, a higher proportion of patients in CPS A/B vs C (73% vs 35%; P = 0.025) and in compensated cirrhosis (80% vs 46.6%; P = 0.043) were found with IDA. Model for End-Stage Liver Disease (MELD) scores were significantly lower in patients with IDA (14.4 vs 17.9 non-ID-anemia; P = 0.005). Similar results were found in the validation cohort: median MELD (16[8-28]non-IDA vs 12 [7-23] IDA; P < 0.001) and within anemic patients IDA was more common in patients with MELD <15 (58%) versus >15 (24%, P < 0.001). Anemia was associated with a significant risk for hepatic decompensation and/or mortality both in the validation (aSHR: 1.65, P = 0.008) and in the derivation cohort (aSHR: 2.11, P < 0.001) and an independent risk factor for hepatic decompensation and/or mortality in compensated patients (aHR: 4.91, P = 0.004).

CONCLUSION

Anemia is highly prevalent in cirrhosis. In compensated cirrhosis, CPS A/B, and low MELD, IDA seems to be the most likely reason for anemia. Furthermore, anemia is associated with a significant risk for hepatic decompensation or mortality during long-term follow up.

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.

Muscle Mass Is Linked to Liver Disease Severity in Pediatric Nonalcoholic Fatty Liver Disease

OBJECTIVE

To investigate the association between muscle mass and liver disease severity in pediatric patients with non-alcoholic fatty liver disease (NAFLD).

STUDY DESIGN

This was a retrospective study of patients aged <20 years followed from 2009 to 2018. Muscle mass was estimated in all patients by measuring magnetic resonance imaging-based total psoas muscle surface area (tPMSA) and correcting for height (tPMSA index = tPMSA/height2). Two cohorts were studied, one with histological confirmation of NAFLD (n = 100) and the other with magnetic resonance imaging (MRI) evidence of hepatic steatosis (n = 236). Histology was scored using Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) criteria. MRI-measured proton density fat fraction (PDFF) and liver stiffness were collected. Demographic, clinical, and socioeconomic status (using a validated Community Deprivation Index [CDI]) were assessed as covariates. Univariate regression analyses, followed by multivariable regression analyses, were used to determine the relationships between tPMSA index and NAS, MRI-PDFF, and liver stiffness, adjusting for clinical, demographic, and CDI variables.

RESULTS

In the multivariable regression analyses, higher steatosis score was associated with a lower tPMSA index (OR, 0.73; 95% CI, 0.56-0.96) and younger age (OR, 0.84; 95% CI, 0.73-0.97). Liver PDFF was also significantly associated with the tPMSA index (P = .029), sex (P = .019), and CDI (P = .005). In contrast, liver stiffness was not associated with tPMSA in multivariable analyses.

CONCLUSIONS

tPMSA index was independently associated with both imaging and histological features of hepatic steatosis severity in children. Future studies should directly explore the presence and directionality of causative links between muscle mass and steatosis, as well as whether interventions that enhance muscle mass can reduce disease severity in children with NAFLD.

Muscle Mass Is Linked to Liver Disease Severity in Pediatric Nonalcoholic Fatty Liver Disease

OBJECTIVE

To investigate the association between muscle mass and liver disease severity in pediatric patients with non-alcoholic fatty liver disease (NAFLD).

STUDY DESIGN

This was a retrospective study of patients aged <20 years followed from 2009 to 2018. Muscle mass was estimated in all patients by measuring magnetic resonance imaging-based total psoas muscle surface area (tPMSA) and correcting for height (tPMSA index = tPMSA/height2). Two cohorts were studied, one with histological confirmation of NAFLD (n = 100) and the other with magnetic resonance imaging (MRI) evidence of hepatic steatosis (n = 236). Histology was scored using Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) criteria. MRI-measured proton density fat fraction (PDFF) and liver stiffness were collected. Demographic, clinical, and socioeconomic status (using a validated Community Deprivation Index [CDI]) were assessed as covariates. Univariate regression analyses, followed by multivariable regression analyses, were used to determine the relationships between tPMSA index and NAS, MRI-PDFF, and liver stiffness, adjusting for clinical, demographic, and CDI variables.

RESULTS

In the multivariable regression analyses, higher steatosis score was associated with a lower tPMSA index (OR, 0.73; 95% CI, 0.56-0.96) and younger age (OR, 0.84; 95% CI, 0.73-0.97). Liver PDFF was also significantly associated with the tPMSA index (P = .029), sex (P = .019), and CDI (P = .005). In contrast, liver stiffness was not associated with tPMSA in multivariable analyses.

CONCLUSIONS

tPMSA index was independently associated with both imaging and histological features of hepatic steatosis severity in children. Future studies should directly explore the presence and directionality of causative links between muscle mass and steatosis, as well as whether interventions that enhance muscle mass can reduce disease severity in children with NAFLD.