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Page 2 of 12 D’Arcangelo et al. Hepatoma Res 2021;7:4 I http://dx.doi.org/10.20517/2394-5079.2020.109

Results: 197 patients were included, of whom, 122 (62%) had sarcopenia. Demographics and severity of cirrhosis
were comparable in patients with vs. without sarcopenia. Overall survival was similar between the groups. When
survival analysis was adjusted for severity of liver disease, sarcopenia was associated with a significantly reduced
survival in decompensated (80% vs. 91%, 1-year post-LT; P = 0.04) but not in compensated (93% vs. 90%, 1-year
post-LT; P = 0.7) patients. In patients with HCC, sarcopenia was associated with a trend towards lower survival
but only in those with HCC beyond Milan criteria. Among secondary outcomes, bacterial infections were more
frequent in patients with vs. without sarcopenia (50% vs. 35%; P = 0.02), whereas hospitalization length and
other complications were comparable between the groups.

Conclusion: Sarcopenia is a common finding in patients awaiting LT and, in those with decompensated cirrhosis, it
is associated with reduced survival after transplantation.

Keywords: Sarcopenia, cirrhosis, hepatocellular carcinoma, liver transplantation, survival

INTRODUCTION
[1]
Sarcopenia is defined as the generalized loss of skeletal muscles mass, strength, and function . It is
reported in approximately 50% of patients with cirrhosis awaiting liver transplantation (LT), with a
[2-9]
relatively higher prevalence in male compared to. female candidates .
Recent evidence suggests that, in patients with cirrhosis, sarcopenia is independently correlated with
increased risks of liver decompensation and mortality, both before and after transplantation [10-12] .

On the other hand, most studies looking at the effects of sarcopenia on post-transplant outcomes have
included heterogeneous cohorts of patients with no adjustments for severity of cirrhosis (compensated vs.
decompensated) and/or indication for transplantation [8,13-20] . This led to rather controversial results with
some studies that found sarcopenia to be associated with increased risk of post-transplant mortality and
others that did not [8,13-20] . Therefore, whether and how sarcopenia impacts post-LT survival remains unclear.

Understanding the effect of sarcopenia on morbidity and mortality after liver transplantation would have
important implications for the management of liver transplant candidates and recipients [21,22] . The goals of
our retrospective study were (1) to evaluate prevalence and characteristics of sarcopenia in a large cohort of
patients with cirrhosis with and without hepatocellular carcinoma (HCC) awaiting LT at a first level center;
and (2) to determine the impact of pre-transplant sarcopenia on morbidity and mortality after LT in these
patients.

METHODS
Patient selection
Adult (> 18 years) patients with cirrhosis who underwent LT between 2010 and 2016 at Padua University
Hospital were retrospectively evaluated to determine eligibility to be included. The diagnosis of cirrhosis
was confirmed with available data including histology, radiology, laboratory, and clinical assessment.
Decompensation was defined by the presence or history of clinically evident decompensating events (i.e.,
ascites, variceal haemorrhage, and hepatic encephalopathy) [23,24] . Diagnosis of HCC was based on guidelines
[25]
from the European Association for the Study of Liver . Patients with HCC were further divided into
[26]
patients with HCC within Milan criteria (MC) and patients with HCC beyond MC . Milan criteria were
defined as follows: single nodule with diameter < 5 cm or no more than 3 nodules with each nodule < 3 cm,
[26]
without angioinvasion and with no extrahepatic metastasis .