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D’Arcangelo et al. Hepatoma Res 2021;7:4 I http://dx.doi.org/10.20517/2394-5079.2020.109 Page 3 of 12

Figure 1. Assessment of sarcopenia in patients with cirrhosis. Using imagine software analysis (Fujifilm Synapse 3D™), the total cross-
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sectional muscle area (CSMA, cm ) at level of 3rd lumbar vertebra was calculated. CSMA was then divided per patient’s height to
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calculate the skeletal muscle index (SMI) (cm /m ). Sarcopenia was defined by SMI < 50 cm /m in male patients and < 39 cm /m in
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female patients, respectively
At screening, patient’s medical records, past medical history, and laboratory data were reviewed for the
following exclusion criteria: absence of abdominal computed tomography scan (CT) within the 6 months
prior to LT, more than one LT, and combined liver-kidney transplantation. Upon having determined
eligibility to be included, patients were categorized into cases (with sarcopenia) and controls (without
sarcopenia).
Assessment of abdominal muscle mass and definition of sarcopenia
Pre-transplant abdominal skeletal muscle mass was assessed by evaluating the last available CT scan within
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6 months prior to LT [Figure 1]. Using image software analysis (Fujifilm Synapse 3D ), one expert operator
calculated the total cross-sectional muscle area (CSMA, cm ) at level of the 3rd lumbar vertebra (L3) [Figure 1].
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CSMA was then divided per patient’s height squared to calculate the skeletal muscle index (SMI) (cm /m ).
[3]
Per previously established cut-offs in patients with cirrhosis awaiting LT , sarcopenia was defined by SMI
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< 50 cm /m in males and < 39 cm /m in females.
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Study design and data collection
This was a single-center, retrospective, case-control study approved by the Padua University Hospital
Ethical Committee (#AOP/0564). The study was conducted in compliance with the Declaration of Helsinki
and a waiver for informed consent was obtained for this retrospective chart review.

Pre-transplant variables collected from the medical records included demographics and body mass index,
diabetes mellitus, aetiology of cirrhosis, duration of wait list time, presence of portal vein thrombosis,
Child class, and MELD (Model for End-Stage Liver Disease) score at time of LT. In patients with HCC, the
number and size of nodules at the last CT scan prior to LT were also collected.

The following post-transplant outcomes were evaluated: length of hospitalization (both in the intensive care
unit and in total), rates of primary non-function (PNF), acute and chronic rejection, early (within 30-day)
infections (i.e., viral, bacterial, and fungal), any biliary complications, and de novo malignancy. Patient’s
survival was recorded at the last available follow-up.

Study objectives
Primary objectives of this study were (1) to determine the prevalence of sarcopenia in a large cohort of