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Low skeletal muscle mass increases risk for liver waitlist mortality
Patients with sarcopenia on the liver transplant waitlist had increased mortality rates and more liver-related complications before waitlist placement, according to a recently published study. The researchers also validated the previously published MELD-Sarcopenia score as a predictive measure for waitlist mortality, although it had limited added value compared with standard MELD score.
“Low skeletal muscle mass (ie, sarcopenia) is an independent risk factor for mortality in a national Dutch cohort of cirrhosis patients listed for liver transplantation. The best model to predict waiting list mortality included both the MELD score and sarcopenia. However, its performance, as expressed in the concordance index, was not significantly better compared with the MELD score on its own,” Jeroen Laurens Ad van Vugt, MD, from the Erasmus MC University Medical Center, the Netherlands, told Healio Gastroenterology and Liver Disease. “An explanation could be that both prioritization and allocation on the one hand and waiting list mortality on the other hand are strongly associated with the MELD score, leading to a self-fulfilling prophecy in studies such as ours.”
To investigate the association between sarcopenia and liver waitlist mortality and validate the MELD-Sarcopenia score, the researchers enrolled 585 patients from three liver transplantation centers in the Netherlands from 2007 to 2014.
The MELD-Sarcopenia score corresponds with a 10.35-point increase in MELD score and is based on preestablished cut-off values for skeletal muscle mass index.
Patients with sarcopenia (n = 254) had significantly lower BMI (25.5 vs. 26.2 kg/m2; P = .001), higher MELD score (16 vs. 13; P < .001), higher MELDNa score (18 vs. 14; P = .001) and shorter median time on waitlist (6 vs. 8 months; P < .001) compared with those without sarcopenia.
Additionally, those with sarcopenia experienced more liver-related complications before waitlist placement (73.2% vs. 62.8%; P = .008), especially ascites (67.3% vs. 54.3%; P = .001) and hepatic encephalopathy (33.6% vs. 20.7%; P < .001).
At the end of the study, 425 patients had undergone liver transplantation, 15 remained on the waitlist, and 145 were removed from the waitlist due to mortality (n = 80), progression of hepatocellular carcinoma beyond Milan criteria, improved liver function, or other reasons.
While the proportion of patients with sarcopenia who underwent liver transplantation did not differ compared with those without sarcopenia, the mortality rate among those with sarcopenia was significantly higher at 1 month (35% vs. 20.8%; P < .001), 3 months (48.4% vs. 32.3%; P < .001), 1 year (84.3% vs. 75.5%; P = .01), 3 years (96.9% vs. 93.7%; P = .078) and overall (20.5% vs. 11.5%; P = .003).
The model with the highest discriminative performance to predict waitlist mortality included MELD score (subdistribution HR = 1.09; 95% CI, 1.06-1.12), hepatic encephalopathy before listing (sHR = 1.8; 95% CI, 1.12-2.87), age (sHR = 1.02; 95% CI, 0.99-1.05) and sarcopenia based on the MELD-Sarcopenia score (sHR = 1.51; 95% CI, 0.97-2.34).
Stratified analyses showed that sarcopenia was significantly present among patients with low MELD scores (sHR = 2.1; 95% CI, 1.05-4.2) but not in the group with high MELD-scores, based on a MELD score cut-off of 15.
“As reflected by a higher proportion of liver-related complications, sarcopenia is strongly correlated with severity of liver disease,” van Vugt and colleagues concluded. “It may therefore contribute to better prioritizing liver transplant candidates, as these patients are at risk to die or to deteriorate prematurely and this risk is currently not reflected in their MELD-score.” – by Talitha Bennett
Disclosure: The authors report no relevant financial disclosures.