Editorial: sarcopenia in liver transplantation-our weakest patients may need the strongest push

Pre-transplant myosteatosis worsens the survival after liver transplantation: A systematic review and meta-analysis

OBJECTIVE

Sarcopenia worsens survival after liver transplantation (LT). However, it remains unclear whether myosteatosis, a pathological phenomenon involving excess fat deposition, also causes adverse effects. We performed a meta-analysis to evaluate the effect of myosteatosis on survival in this patient population.

METHODS

We searched PubMed, EMBASE, Web of Science, and Cochrane databases through March 30, 2025 for articles that focused on the association between myosteatosis and post-LT mortality. The Newcastle-Ottawa Scale was used to assess the quality of the studies. The primary outcome was mortality rate. Meta-analyses were performed using Review Manager software. Study quality, publication bias, and subgroup analyses were performed.

RESULT

28 studies involving 7068 patients were included. The studies were of moderate-to-high quality. The pooled results suggested that myosteatosis as a categorical variable was an independent predictor of mortality, both in univariate analyses (hazard ratio[HR] = 1.80, 95%CI 1.59-2.05) and multifactorial analyses (HR = 1.69, 95%CI 1.51-1.89). Similar results were found when myosteatosis was treated as a continuous variable. Further pooling of data comparing patients with and without myosteatosis within 6-month, one, three, and five years of follow-up (odds ratio[OR] = 5.49, 95%CI 3.69-8.17, OR = 1.93, 95%CI: 1.55-2.41, OR = 1.62, 95%CI 1.30-2.00, and OR = 1.68, 95%CI 1.28-2.19, respectively) also suggested a high mortality risk in myosteatosis patients. Finally, sensitivity analyses based on the different definitions of myosteatosis confirmed these results. In addition, patients with myosteatosis had significantly increased ICU stay (mean difference[MD] = 7.86 days; 95 % CI, 2.41-13.30), hospital stay (MD = 2.04 days, 95 % CI, 0.56-3.53), and more post-LT complications (OR = 2.35, 95 % CI 1.93-2.87) than those without myosteatosis.

CONCLUSIONS

Our results revealed that myosteatosis is associated with an increased risk of mortality in patients undergoing LT. These findings indicate that myosteatosis can be a tool to identify high-risk patients and make informed clinical decisions during perioperative management.

Improving the prognosis before and after liver transplantation: Is muscle a game changer?

Liver transplantation (LT) is currently the only curative treatment option for selected patients with end stage liver disease or hepatocellular carcinoma. Improving waiting list-mortality, post-transplant morbidity and mortality and refining the selection of the patients remain our current central objectives. In this field, different concepts dealing with nutrition and the muscle such as sarcopenia, malnutrition, frailty or myosteatosis have emerged as possible game changers. For more than a decade, many prospective studies have demonstrated that sarcopenia and frailty are major predictive factors of mortality in the waiting list but also after LT. Malnutrition is also a well-known risk factor for morbidity and mor-tality. Muscle composition is a newer concept giving insight on muscle quality which has also been shown to be linked to poorer outcomes. Each of these terms has a precise definition as well as pathophysiological mechanisms. The bi-directional liver-muscle axis makes sense in this situation. Defining the best, easy to use in clinical practice tools to assess muscle quality, quantity, and function in this specific population and developing quality prospective studies to identify interventional strategies that could improve these parameters as well as evaluate the effect on mortality are among the important challenges of today.

Frailty, sarcopenia and mortality in cirrhosis: what is the best assessment, how to interpret the data correctly and what interventions are possible?

Cirrhosis-induced sarcopenia plays a deleterious role in patients on the waiting list of transplantation. Liver frailty index (LFI) calculation based on easy measurable clinical parameters (muscle strength and balance data) seems therefore accurate for identifying patients at risk for waiting list mortality. However, some questions remain open such as the difficult clinical testing of patients with encephalopathy, the comparison of these clinical data with the radiological evaluation of muscle quantity and quality, the attitude to adopt towards these patients identified as fragile (emergency versus futile transplantation?) and the possible benefit of interventions (nutrition and/or exercise). Finally, recent data show that the deterioration of the muscle condition occurs early prior to the development of advanced fibrosis (specifically in fatty liver disease). This underlines the interest of evaluating the muscle compartment during the pathogenesis of liver diseases, also before the emergence of cirrhosis.

Cirrhosis and insulin resistance: current knowledge, pathophysiological mechanisms, complications and potential treatments

End-stage chronic liver diseases are often associated with insulin resistance (IR) and diabetes mellitus (DM). Indeed, to quantify insulin sensitivity the euglycemic clamp technique was utilized, allowing the following to be stated: in small groups of patients, an IR in almost all cirrhotic patients can be observed, compared with a control group. Additionally, it has been demonstrated that IR in cirrhosis is linked to a decreased peripheral (muscle) glucose uptake rather than an increased liver glucose production. The homoeostasis model of IR (HOMA-IR) technique, devised only later, was then exploited to assess this same phenomenon in a larger sample population. The research established that even in patients with preserved liver function, cirrhosis is associated with significant alterations in glucose homoeostasis levels. The purpose of the present paper is to present the current research around the affiliation of cirrhosis and IR, discuss potential mechanisms explaining the association between cirrhosis and IR (i.e. endocrine perturbation, liver inflammation, altered muscle mass and composition, altered gut microbiota and permeability), complications that can arise as well as treatment options, through a critical review of the literature surrounding this subject. This research will also be investigating the beneficial impact, if there is any, of identifying and curing IR in patients with cirrhosis.