Daniel M. Keller, PhD

November 11, 2012

BOSTON, Massachusetts — Although sarcopenia may be present in more than one third of cirrhotic patients after liver transplantation, it does not increase mortality after transplantation, according to new research.

Presenting his study results here at the American Association for the Study of Liver Diseases (AASLD) 63rd Annual Meeting, Aldo Montano-Loza, MD, assistant professor in the Division of Gastroenterology and the Liver Unit at the University of Alberta in Edmonton, Canada, said that sarcopenia may resolve in some cases after transplantation.

Sarcopenia is associated with increased mortality in patients with cirrhosis, but it was unknown how it affected morbidity or mortality after liver transplantation. "Until now, there is no information to support that we should deny transplant for these patients, but also there is still no information that we should try to give them extra points to try to give them some priority for liver transplant," he said.

The study population was 133 cirrhotic patients who had had a computed tomography (CT) scan at the level of the third lumbar vertebra before transplantation, from which skeletal muscle cross-sectional area could be calculated. Dr. Montano-Loza said that the cross-sectional area of muscle at this level has been shown to correlate well with total body skeletal muscle mass. Sarcopenia is defined as muscle mass 2 standard deviations below sex-specific means.

Ninety patients (68%) were men, and the mean age at transplantation was 55 ± 1 years (range, 23 - 73 years) in both the group of patients with sarcopenia (n = 51) and those without sarcopenia (n = 82). Cirrhosis was mainly from hepatitis (44%), alcohol (19%), or autoimmune liver diseases (17%).

The lumbar skeletal muscle index of patients with sarcopenia was 44 ± 1 cm2/m2 of body surface area vs 54 ± 1 cm2/m2 (P < .001). Sarcopenia occurred more frequently in men than women (49% vs 16%, respectively; P < .001), in patients with moderate to severe ascites (45% vs 26%; P = .02), and in patients with higher Child-Pugh (10 ± 0.5 vs 8 ± 0.5 points; P = .009) and Model for End-Stage Liver Disease (MELD, 20 ± 2 vs 14 ± 1; P = .008) scores. It was also associated with a higher international normalized ratio (1.7 ± 0.1 vs 1.4 ± 0.1; P = .03).

The overall survival rates for all patients were 93% at 1 year and 85% at 5 years. For patients without sarcopenia, survival at 5 years was 88% vs 77% for sarcopenic patients. At 10 years, the survival rates were 85% and 69%, respectively. There was no significant difference in the median survival for the 2 groups — 12 ± 1 years without sarcopenia and 10 ± 2 years with sarcopenia (log rank, P = .1).

There were nonsignificant trends toward more infections after transplantation among the sarcopenic patients (8%) compared with nonsarcopenic patients (1%) and longer hospital stays from transplantation to discharge (34 vs 24 days). "But we haven't found that that impacts survival," Dr. Montano-Lora told Medscape Medical News.

Sarcopenia May Resolve

Among the patients who had sarcopenia before transplantation, it resolved in 22% of patients after transplantation.

"We saw that survival after liver transplant was not significantly different between sarcopenic and nonsarcopenic patients," Dr. Montano-Lora concluded. "Sarcopenia should not preclude for a liver transplant in patients with cirrhosis, and further studies are going to be necessary to confirm if these patients may be candidates for priority for liver transplant sooner before they have worse outcomes."

He explained that patients with cirrhosis and sarcopenia have a higher mortality risk when they do not receive a liver transplant. "So maybe if sarcopenia is a risk factor for mortality and doesn't affect the impact after liver transplant, they should be considered for some type of prioritization, like MELD type, in order to give them the opportunity to receive the transplant before they have a fatal outcome. But that is something that has to be analyzed in subsequent studies," Dr. Montano-Lora said.

Because sarcopenia is not included in the MELD score and does not appear to correlate well with it, patients with sarcopenia may have a higher risk of dying while waiting for a liver transplant, "and that's not going to be reflected in the conventional score that we use to allocate the liver transplants," Dr. Montano-Lora noted.

William Bernal, MD, reader in hepatology and intensive care medicine at King's College Hospital, London, United Kingdom, commented to Medscape Medical News that what struck him about this study is that sarcopenia is very common in patients with chronic liver disease, that it is underappreciated, and that it has very strong effects on the outcomes of these patients.

He added that "something not touched in this poster is actually quality of life is very significantly impaired in these patients. The really key thing about this is that in other chronic diseases where sarcopenia has been recognized as being important for a long period of time, there are effective interventions that can be brought in. So physical training interventions improve quality of life and actually prolong life as well."

Dr. Bernal mentioned that he presented evidence a couple of years ago that grip strength predicts one's length of stay in intensive care "as well as anything else that we have at the moment. I think it's part of the whole panoply of sarcopenia markers that we have."

He said that at this point, "Certainly nobody would be using these sorts of measures as indications for listing or delisting or not considering someone for transplantation. What I think they probably would do is they would reinforce the importance of physical therapy and nutritional support for these patients."

The study did not receive any commercial support. Dr. Montano-Loza and Dr. Bernal, who was not involved in the study, have disclosed no relevant financial relationships.

The Liver Meeting 2012: American Association for the Study of Liver Diseases (AASLD) 63rd Annual Meeting. Abstract 651. Presented November 10, 2012.