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Page 8 of 12 D’Arcangelo et al. Hepatoma Res 2021;7:4 I http://dx.doi.org/10.20517/2394-5079.2020.109

Table 2. Secondary outcomes in patients with vs. without sarcopenia
Patients with sarcopenia Patients without sarcopenia
(n = 122) (n = 75) P values
Hospitalization (days)
ICU 6 (6) 6.2 (6.1) 0.5
Total 23 (19) 24 (16) 0.7
PNF, n (%) 4 (3%) 4 (5%) 0.4
Bacterial infections, n (%) 63 (50%) 26 (35%) 0.02
Fungal infections, n (%) 13 (10%) 5 (7%) 0.3
Viral infections, n (%) 11 (9%) 4 (5%) 0.3
Biliary stenosis, n (%) 23 (21%) 22 (30%) 0.1
Acute rejection, n (%) 15 (12%) 8 (10%) 0.7
Chronic rejection, n (%) 1 (1.4%) 1 (2.1%) 0.2
De novo malignancy, n (%) 4 (5.7%) 3 (6.5%) 0.3
Continuous variable expressed as mean (SD), categorical data expressed as frequency and percentage. ICU: intensive care units; PNF:
primary non-function

DISCUSSION
Sarcopenia is a common finding in patients with cirrhosis awaiting liver transplantation [13-18,20,27] ; however,
[19]
its impact on post-transplant outcomes remains unclear .
Our study shows, in a large retrospective cohort of patients with cirrhosis who underwent liver
transplantation, that in the general cohort, sarcopenia is not associated with reduced post-transplant
survival. On the other hand, when the analysis was adjusted for severity of cirrhosis (i.e., compensated
and decompensated patients analysed separately), we found that patients with decompensated cirrhosis
with sarcopenia had a significantly lower survival than controls with decompensated cirrhosis without
sarcopenia. By contrast, this effect was not observed in patients with compensated cirrhosis, in whom
survival rates were similar between sarcopenic and non-sarcopenic patients. It may be that in sarcopenic
patients who undergo liver transplant with compensated liver disease, the negative effect of sarcopenia
is relatively less important compared to other factors such as recurrence of primary liver disease. An
alternative explanation could be that in compensated patients after LT, there is a more rapid or more
significant improvement in muscle mass after LT compared with those who undergo transplantation with
decompensated cirrhosis, which prevents the negative sequalae associated with sarcopenia. Further studies
that look at the changes of muscle mass after transplantation in compensated vs. decompensated patients at
the time of transplantation are required to test this hypothesis.

These findings suggest that the impact of sarcopenia on post-transplant survival may vary significantly
according to the severity of liver dysfunction at time of transplantation and that proactive treatment of pre-
transplant sarcopenia should be especially considered in decompensated candidates in whom improvement
of muscle mass could potentially translate into improvement in post-transplant survival.

Some studies have previously assessed the effect of pre-transplant sarcopenia on the risk of complications
and survival after transplantation, and have reported conflicting results with sarcopenia being associated
with increased risk of death in some studies but not in others [14,16-18,27,28] . In fact, in a very recent meta-
[12]
analysis, van Vugt et al. suggested that the current evidence is not robust enough to support the
association between sarcopenia and increased risk of death after transplantation. While awaiting large
prospective studies to evaluate the impact of pre-transplant sarcopenia on post-transplant mortality, our
findings suggest that the severity of liver dysfunction at the time of transplantation is a key factor in this
analysis and it should be taken into consideration when assessing the clinical impact of sarcopenia in this
patient population.