Sarcopenia of thoracic muscle mass is not a risk factor for survival in lung transplant recipients

The Path Forward: A Review on Enhanced Recovery After Cardiothoracic Transplantation

Enhanced Recovery After Surgery (ERAS) protocols represent a contemporary, evidence-based strategy for optimizing perioperative care to enhance patient outcomes through a standardized approach. While ERAS protocols have demonstrated significant benefits across a range of surgical specialties, specific guidelines tailored for cardiothoracic transplantation have yet to be developed. Given the unique complexity and heightened vulnerability of transplant patients, the implementation of ERAS principles in this context could potentially mitigate postoperative complications, reduce the length of hospital stays, and facilitate improved recovery trajectories. This review highlights the critical importance of adapting and applying ERAS methodologies in cardiothoracic transplantation to achieve improved surgical outcomes and elevate patient quality of life.

Computed Tomography-Based Body Composition is Related to Perioperative Morbidity in Older Lung Transplant Recipients

BACKGROUND

 In older patients, a limited physical reserve is considered a contraindication for lung transplantation (LTx). Herein, we aimed to establish a computed tomography (CT)-based quantification of physical reserve in older patients scheduled for transplantation.

METHODS

 This retrospective study included patients older than 60 years who received LTx. Semiautomatic measurements of the mediastinal fat area and the dorsal muscle group area in pretransplantation CT scans were performed, and normalized data were correlated with clinical parameters.

RESULTS

 Patients (n = 108) were assigned into three groups (Musclehighfatlow [n = 25], Musclelowfathigh [n = 24], and other combinations [n = 59]). The Musclelowfathigh group had a significantly increased risk of wound infections (p = 0.002) and tracheostomy (p = 0.001) compared with Musclehighfatlow patients. The median length of intensive care unit stay (25 vs. 3.5 days; p = 0.002) and the median length of hospital stay (44 vs. 22.5 days; p = 0.013) post-LTx were significantly prolonged in the Musclelowfathigh group. Significantly more patients in this group had a prolonged ventilation time (11 vs. 0; p < 0.001).

CONCLUSION

 Body composition parameters determined in pretransplant chest CT scans in older LTx candidates might aid in identifying high-risk patients with a worse perioperative outcome after LTx.

Radiomics of spinal muscles: toward a radiological biomarker for allograft rejection in lung transplant

PURPOSE

To assess the role of muscle composition and radiomics in predicting allograft rejection in lung transplant.

MATERIAL AND METHODS

The last available HRCT before surgery of lung transplant candidates referring to our tertiary center from January 2010 to February 2020 was retrospectively examined. Only scans with B30 kernel reconstructions and 1 mm slice thickness were included. One radiologist segmented the spinal muscles of each patient at the level of the 11th dorsal vertebra by an open-source software. The same software was used to extract Hu values and 72 radiomic features of first and second order. Factor analysis was applied to select highly correlating features and then their prognostic value for allograft rejection was investigated by logistic regression analysis (level of significance p < 0.05). In case of significant results, the diagnostic value of the model was computed by ROC curves.

RESULTS

Overall 200 patients had a HRCT prior to the transplant but only 97 matched the inclusion criteria (29 women; mean age 50.4 ± 13 years old). Twenty-one patients showed allograft rejection. The following features were selected by the factor analysis: cluster prominence, Imc2, gray level non-uniformity normalized, median, kurtosis, gray level non-uniformity, and inverse variance. The radiomic-based model including also Hu demonstrated that only the feature Imc2 acts as a predictor of allograft rejection (p = 0.021). The model showed 76.6% accuracy and the Imc2 value of 0.19 demonstrated 81% sensitivity and 64.5% specificity in predicting lung transplant rejection.

CONCLUSION

The radiomic feature Imc2 demonstrated to be a predictor of allograft rejection in lung transplant.

Computed tomography body composition and clinical outcomes following lung transplantation in cystic fibrosis

BACKGROUND

Low muscle mass is common in patients approaching lung transplantation and may be linked to worse post-transplant outcomes. Existing studies assessing muscle mass and post-transplant outcomes include few patients with cystic fibrosis (CF).

METHODS

Between May 1993 and December 2018, 152 adults with CF received lung transplants at our institution. Of these, 83 met inclusion criteria and had usable computed tomography (CT) scans. Using Cox proportional hazards regression, we evaluated the association between pre-transplant thoracic skeletal muscle index (SMI) and our primary outcome of death after lung transplantation. Secondary outcomes, including days to post-transplant extubation and post-transplant hospital and intensive care unit (ICU) length of stay, were assessed using linear regression. We also examined associations between thoracic SMI and pre-transplant pulmonary function and 6-min walk distance.

RESULTS

Median thoracic SMI was 26.95 cm²/m² (IQR 23.97, 31.32) for men and 22.83 cm²/m² (IQR 21.27, 26.92) for women. There was no association between pre-transplant thoracic SMI and death after transplant (HR 1.03; 95% CI 0.95, 1.11), days to post-transplant extubation, or post-transplant hospital or ICU length of stay. There was an association between pre-transplant thoracic SMI and pre-transplant FEV1% predicted (b = 0.39; 95% CI 0.14, 0.63), with higher SMI associated with higher FEV1% predicted.

CONCLUSIONS

Skeletal muscle index was low for men and women. We did not identify a significant relationship between pre-transplant thoracic SMI and post-transplant outcomes. There was an association between thoracic SMI and pre-transplant pulmonary function, confirming the potential value of sarcopenia as a marker of disease severity.

Sarcopenia Predicts Outcomes After Lung Transplantation in Older Lung Transplant Candidates

Background

As lung transplantation (LT) expands to older recipients, objective approaches to evaluate the aging are needed to optimize posttransplantation outcomes. Frailty assessment and sarcopenia have shown promise as tools for predicting clinical outcomes.

Methods

Patients older than 55 years undergoing evaluation for LT were enrolled in an institutional review board-approved study. Sarcopenia was measured on pretransplantation chest computed tomography images, measuring cross-sectional area and average attenuation of the pectoralis major muscle at 1 slice above the aortic arch. Frailty was measured using the Fried frailty phenotype (FFP) and Short Performance Physical Battery (SPPB).

Results

The study evaluated 84 patients with results of computed tomography of the chest available for review; 63% were classified as frail or prefrail by SPPB and 53% were frail by FFP. Sex-corrected sarcopenia was associated with frailty by FFP (P = .004) or SPPB (P = .044). Sarcopenia, measured by area or average attenuation, was significantly associated with length of stay after transplantation (P = .017 and P = .022, respectively), with a median 12 days for those with higher muscle mass compared with 21 days for those with lower muscle mass. Total time in the hospital in the first year after transplantation was also associated with sarcopenia by area (P = .090) or average attenuation (P = .046).

Conclusions

A multifaceted approach to the evaluation of older patients can improve risk stratification, optimizing organ allocation to improve LT outcomes.

Evaluation of Frailty Measures and Short-term Outcomes After Lung Transplantation

BACKGROUND

Frailty, measured as a single construct, is associated variably with poor outcomes before and after lung transplantation. The usefulness of a comprehensive frailty assessment before transplantation is unknown.

RESEARCH QUESTION

How are multiple frailty constructs, including phenotypic and cumulative deficit models, muscle mass, exercise tolerance, and social vulnerabilities, measured before transplantation, associated with short-term outcomes after lung transplantation?

STUDY DESIGN AND METHODS

We conducted a retrospective cohort study of 515 lung recipients who underwent frailty assessments before transplantation, including the short physical performance battery (SPPB), transplant-specific frailty index (FI), 6-min walk distance (6MWD), thoracic sarcopenia, and social vulnerability indexes. We tested the association between frailty measures before transplantation and outcomes after transplantation using logistic regression to model 1-year survival and zero-inflated negative binomial regression to model hospital-free days (HFDs) in the first 90 days after transplantation. Adjustment covariates included age, sex, native lung disease, transplantation type, lung allocation score, BMI, and primary graft dysfunction.

RESULTS

Before transplantation, 51.3% of patients were frail by FI (FI ≥ 0.25) and no patients were frail by SPPB. In multivariate adjusted models that also included FI, SPPB, and 6MWD, greater frailty by FI, but not SPPB, was associated with fewer HFDs (-0.006 per 0.01 unit worsening; 95% CI, -0.01 to -0.002 per 0.01 unit worsening) among discharged patients. Greater SPPB deficits were associated with decreased odds of 1-year survival (OR, 0.51 per 1 unit worsening; 95% CI, 0.28-0.93 per 1 unit worsening). Correlation among frailty measurements overall was poor. No association was found between thoracic sarcopenia, 6MWD, or social vulnerability assessments and short-term outcomes after lung transplantation.

INTERPRETATION

Both phenotypic and cumulative deficit models measured before transplantation are associated with short-term outcomes after lung transplantation. Cumulative deficit measures of frailty may be more relevant in the first 90 days after transplantation, whereas phenotypic frailty may have a stronger association with 1-year survival.

Comparison of CT derived body composition at the thoracic T4 and T12 with lumbar L3 vertebral levels and their utility in patients with rectal cancer

BACKGROUND

Computed tomography (CT) derived body composition measurements of sarcopenia are an emerging form of prognostication in many disease processes. Although the L3 vertebral level is commonly used to measure skeletal muscle mass, other studies have suggested the utilisation of other segments. This study was performed to assess the variation and reproducibility of skeletal muscle mass at vertebral levels T4, T12 and L3 in pre-operative rectal cancer patients. If thoracic measurements were equivalent to those at L3, it will allow for body composition comparisons in a larger range of cancers where lumbar CT images are not routinely measured.

RESEARCH METHODS

Patients with stage I - III rectal cancer, undergoing curative resection from 2010 - 2014, were assessed. CT based quantification of skeletal muscle was used to determine skeletal muscle cross sectional area (CSA) and skeletal muscle index (SMI). Systematic differences between the measurements at L3 with T4 and T12 vertebral levels were evaluated by percentile rank differences to assess distribution of differences and ordinary least product regression (OLP) to detect and distinguish fixed and proportional bias.

RESULTS

Eighty eligible adult patients were included. Distribution of differences between T12 SMI and L3 SMI were more marked than differences between T4 SMI and L3 SMI. There was no fix or proportional bias with T4 SMI, but proportional bias was detected with T12 SMI measurements. T4 CSA duplicate measurements had higher test-retest reliability: coefficient of repeatability was 34.10 cm² for T4 CSA vs 76.00 cm² for T12 CSA. Annotation time (minutes) with L3 as reference, the median difference was 0.85 for T4 measurements and -0.03 for T12 measurements. Thirty-seven patients (46%) had evidence of sarcopenia at the L3 vertebral level, with males exhibiting higher rates of sarcopenia. However, there was no association between sarcopenia and post-operative complications, recurrence or hospital LOS (length of stay) in patients undergoing curative resection.

CONCLUSIONS

Quantifying skeletal muscle mass at the T4 vertebral level is comparable to measures achieved at L3 in patients with rectal cancer, notwithstanding annotation time for T4 measurements are longer.

Sarcopenia as a Predictor of Short- and Long-Term Outcomes in Patients Surgically Treated for Malignant Pleural Mesothelioma

Surgery for malignant pleural mesothelioma (MPM) should be reserved only for patients who have a good performance status. Sarcopenia, a well-known predictor of poor outcomes after surgery, is still underinvestigated in MPM. The aim of this study is to evaluate the role of sarcopenia as a predictor of short-and long-term outcomes in patients surgically treated for MPM. In our analysis, we included patients treated with a cytoreductive intent in a multimodality setting, with both pre- and post-operative CT scans without contrast available. We excluded those in whom a complete macroscopic resection was not achieved. Overall, 86 patients were enrolled. Sarcopenia was assessed by measuring the mean muscular density of the bilateral paravertebral muscles (T12 level) on pre-and post-operative CTs; a threshold value of 30 Hounsfield Units (HU) was identified. Sarcopenia was found pre-operatively in 57 (66%) patients and post-operatively in 61 (74%). Post-operative sarcopenic patients had a lower 3-year overall survival (OS) than those who were non-sarcopenic (34.9% vs. 57.6% p = 0.03). Pre-operative sarcopenia was significantly associated with a higher frequency of post-operative complications (65% vs. 41%, p = 0.04). The evaluation of sarcopenia, through a non-invasive method, would help to better select patients submitted to surgery for MPM in a multimodality setting.

Lung transplantation for interstitial lung disease

Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.

Erector spinae muscle radiographic density is associated with survival after lung transplantation

OBJECTIVE

The study objective was to verify whether low preoperative radiographic density of erector spinae muscles is associated with poor prognosis after lung transplantation.

METHODS

Preoperative chest computed tomography scans for patients who underwent deceased-donor lung transplantation between 2013 and 2019 at Kyoto University Hospital were retrospectively retrieved. The radiographic density of erector spinae muscles was quantitatively evaluated as the mean attenuation of erector spinae muscles, and low mean radiographic density of the erector spinae muscles was defined as a mean radiographic density of the erector spinae muscles value below the median value for all patients. Overall survival and chronic lung allograft dysfunction-free survival with high and low mean radiographic density of the erector spinae muscles were estimated using the Kaplan-Meier method and evaluated by the log-rank test, as well as by univariate and multivariate Cox proportional hazard analyses.

RESULTS

Of the 107 adult patients who underwent primary transplantation, 96 underwent at least 1 chest computed tomography scan within 24 hours before lung transplantation. The median mean radiographic density of the erector spinae muscles in these 96 patients was 49.2 Hounsfield units. A low mean radiographic density of the erector spinae muscles value was significantly associated with decreased overall survival (hazard ratio, 4.50; P = .030) and chronic lung allograft dysfunction-free survival (hazard ratio, 3.18; P = .028) in the multivariate analysis. Additionally, patients with preoperative steroid use and a low mean radiographic density of the erector spinae muscles value had a worse overall survival (P < .001) and chronic lung allograft dysfunction-free survival (P < .001) than patients with preoperative steroid use and a high mean radiographic density of the erector spinae muscles value and those without preoperative steroid use.

CONCLUSIONS

Low mean radiographic density of the erector spinae muscles was closely associated with a poor prognosis after lung transplantation. The prognosis was particularly poor in patients with preoperative steroid use and a low mean radiographic density of the erector spinae muscles. These results may be useful when considering the indications for lung transplantation or preoperative interventions. VIDEO ABSTRACT.

Recovery of physical function in lung transplant recipients with sarcopenia

Background

Lung transplant (LTX) can provide a survival benefit and improve physical function for selected patients with advanced pulmonary disease. Sarcopenia is a systemic muscle-failure that can be found in a variety of life stages and disabilities. In this study, we follow the evolution of each variable defined in sarcopenia and the outcomes in LTX recipients with post-transplant sarcopenia.

Methods

Patients who underwent LTX at Tohoku University Hospital between 2013 and 2018 were consecutively included in the retrospective cohort study, with follow-up to 2019. Sarcopenia was defined by low muscle mass (the cross-sectional area (CSA) of erector spinae muscle (ESM) in thoracic CT with a threshold < 17.24 cm²/m²) and either low muscle strength (hand-grip with a threshold of < 26 kg in males and of < 18 kg in females) or physical performance (6-min walk distance with a threshold < 46.5% of predicted distance).

Results

Fifty-five recipients were included into the study, of whom 19 patients were defined as sarcopenic and 36 as non-sarcopenic. The muscle mass improved after transplant in both sarcopenic and non-sarcopenic individuals: the median ESM-CSA enlarged from 17.25 cm²/m² in 2 months post-LTX to 18.55 cm²/m² in 12 months (p < 0.001) and 17.63 cm²/m² in 36 months (p < 0.001) in non-sarcopenic individuals, while in sarcopenic patients it improved from 13.36 cm²/m² in 2 months to 16.31 cm²/m² in 12 months (p < 0.005) and 18.01 cm²/m² in 36 months (p < 0.001). The muscle mass in sarcopenia substantially recovered to close to non-sarcopenic conditions within 36-months (p < 0.001 in 2 months and p = 0.951 in 36 months). Accordingly, muscle strength and physical performance in both groups improved over time. No difference in survival was seen in both groups (Log-rank p = 0.096), and sarcopenia was not associated with an overall hazard of death (p = 0.147). There was no difference in the cumulative incidence of chronic lung allograft dysfunction between patients with or without sarcopenia (Log-rank p = 0.529).

Conclusions

Even patients with post-transplant sarcopenia have a chance to recover physical function to levels close to those without sarcopenia several years post LTX.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01442-5.

Clinical outcomes associated with computed tomography-based body composition measures in lung transplantation: a systematic review

Computed tomography (CT) is gaining increased recognition in the assessment of body composition in lung transplant (LTx) candidates as a prognostic marker of post-transplant outcomes. This systematic review was conducted to describe the methodology of CT measures of body composition used in LTx patients and its association with post-transplant outcomes. Six databases were searched (inception-April 2020) for studies of adult LTx patients with thoracic or abdominal CT measures [muscle cross-sectional area (CSA) and/or adiposity]. Thirteen articles were included with 1911 LTx candidates, 58% males, mean age range (48-61 years) and body mass index of 21.0-26.1 kg/m2 . Several methods were utilized using thoracic or abdominal CT scans to assess skeletal muscle (n = 11) and adiposity (n = 4) at various anatomic locations (carina, thoracic, and lumbar vertebrae), differing muscle groups, and adipose tissue compartments. Low muscle mass was associated with adverse outcomes in 6/11 studies, including longer mechanical ventilation days (n = 2), intensive care (n = 2) and hospital stay (n = 2), and mortality (n = 4). Greater subcutaneous and mediastinal fat were associated with increased risk of primary graft dysfunction (n = 2), but implications of adiposity on survival were variable across four studies. Further standardization of CT body composition assessments is needed to assess the prognostic utility of these measures on LTx outcomes.

Pectoralis muscle area is associated with bone mineral density and lung function in lung transplant candidates

Loss of bone mineral density and skeletal muscle area are linked in lung transplant patients. This loss is greater in patients with restrictive compared with obstructive lung diseases.

INTRODUCTION

Sarcopenia and osteoporosis are associated with aging and chronic illnesses and may be linked in patients with advanced lung disease. Pectoralis muscle index (PMI) quantitated on computed tomography (CT) of the chest can be used to measure skeletal muscle mass. This study aimed to determine the relationship of PMI to clinical parameters including bone mineral density (BMD) in candidates for lung transplantation.

METHODS

A retrospective review of transplant candidates at a single center was performed. Demographic, anthropomorphic, and clinical data were recorded. Pectoralis muscle area (PMA) was determined on an axial slice from a chest CT. PMI was calculated as the PMA divided by height squared. BMD was obtained from routine dual-energy X-ray absorptiometry (DXA) scan.

RESULTS

In 226 included patients, mean PMI was 8.2 ± 3.0 cm²/m² in males and 6.1 ± 2.1 cm²/m² in females. Osteopenia was present in 44.4%, and 23.2% of patients had osteoporosis. Patients with obstructive lung disease had lower body mass index (22.0 ± 4.9 versus 27.9 ± 4.9 kg/m², p < 0.001), PMI (6.0 ± 2.3 versus 8.2 ± 2.8 cm²/m², p < 0.001), and BMD (- 2.3 ± 1.1 versus - 1.3 ± 1.1, p < 0.001) compared with patients with restrictive lung disease. PMI was a significant predictor of BMD (β = 0.16, p < 0.001).

CONCLUSION

The association between muscle area and BMD in lung transplant candidates suggests that similar mechanisms may underlie the development of both. Differences in PMI and BMD in patients with obstructive versus restrictive lung disease may result from differences in respiratory physiology or disease processes.

A Comparison of Frailty Measures at Listing to Predict Outcomes After Lung Transplantation

BACKGROUND

Sarcopenia may be an important predictive factor of outcomes after lung transplantation (LTx). Serum albumin and the 6-minute walk distance (6MWD) have been shown to be a marker of LTx outcomes. We measured sarcopenia, albumin, and 6MWD in a cohort of LTx patients and analyzed the utility of these as markers of outcomes for LTx patients.

METHODS

We retrospectively identified LTx recipients from 2013-2018 at our institution who underwent computed tomographic imaging during their listing evaluation. From that image, we measured skeletal muscle cross-sectional surface area at the third lumbar vertebral level, and sarcopenia was diagnosed by established cutoffs. Associations between sarcopenia, albumin, 6MWD, and survival, and hospital length of stay, complications, readmissions, and discharge destination were evaluated.

RESULTS

Sarcopenia was found in 72% (95 of 132) of patients, 18% (24 of 131) of patients were hypoalbuminemic, and 41% had a low 6MWD. Survival was not associated with presence of sarcopenia (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.46-2.42) or low 6MWD (HR, 0.86; 95% CI, 0.410-1.83). Hospital length of stay, complications, readmissions, and discharge destination were not influenced by sarcopenia or 6MWD. In contrast, hypoalbuminemia was independently associated with decreased survival (HR, 2.25; 95% CI, 1.04-4.85) and a higher grade of postoperative complications (P = .04).

CONCLUSIONS

Sarcopenia is prevalent in LTx patients. Neither sarcopenia nor 6MWD predicted mortality or short-term outcomes after LTx. This is in contrast to albumin levels, which were inversely associated with survival and complications. Albumin shows promise as an important predictor of mortality and short-term outcomes after LTx.

Association of Chest CT-Based Quantitative Measures of Muscle and Fat with Post-Lung Transplant Survival and Morbidity: A Single Institutional Retrospective Cohort Study in Korean Population

OBJECTIVE

Abnormal body composition is an important modifiable risk factor in lung transplantation. Therefore, precise quantification of different body components, including muscle and fat, may play an important role in optimizing outcomes in lung transplant patients. The purpose of the study was to investigate the prognostic significance of muscle and subcutaneous fat mass measured on chest CT with regard to lung transplantation survival and other post-transplant outcomes.

MATERIALS AND METHODS

The study population included 45 consecutive adult lung transplant recipients (mean age of 47.9 ± 12.1 years; 31 males and 14 females) between 2011 and 2017. Preoperative cross-sectional areas of muscle and subcutaneous fat were semi-automatically measured on axial CT images at the level of the 12th thoracic vertebra (T12). Additional normalized indexed parameters, adjusted for either height or weight, were obtained. Associations of quantitative parameters with survival and various other post-transplant outcomes were evaluated.

RESULTS

Of the 45 patients included in the present study, 10 mortalities were observed during the follow-up period. Patients with relative sarcopenia (RS) classified based on height-adjusted muscle area with a cut-off value of 28.07 cm²/m² demonstrated worse postoperative survival (log-rank test, p = 0.007; hazard ratio [HR], 6.39:1) despite being adjusted for age, sex, and body mass index (HR, 8.58:1; p = 0.022). Weight-adjusted parameters of muscle area were negatively correlated with duration of ventilator support (R = -0.54, p < 0.001) and intensive care unit (ICU) stay (R = -0.33, p = 0.021).

CONCLUSION

Patients with RS demonstrate worse survival after lung transplantation that those without RS. Additionally, quantitative parameters of muscles measured at the T12 level on chest CT were associated with the duration of post-lung transplant ventilator support and duration of stay in the ICU.

Report from the American Society of Transplantation on frailty in solid organ transplantation

A consensus conference on frailty in kidney, liver, heart, and lung transplantation sponsored by the American Society of Transplantation (AST) and endorsed by the American Society of Nephrology (ASN), the American Society of Transplant Surgeons (ASTS), and the Canadian Society of Transplantation (CST) took place on February 11, 2018 in Phoenix, Arizona. Input from the transplant community through scheduled conference calls enabled wide discussion of current concepts in frailty, exploration of best practices for frailty risk assessment of transplant candidates and for management after transplant, and development of ideas for future research. A current understanding of frailty was compiled by each of the solid organ groups and is presented in this paper. Frailty is a common entity in patients with end-stage organ disease who are awaiting organ transplantation, and affects mortality on the waitlist and in the posttransplant period. The optimal methods by which frailty should be measured in each organ group are yet to be determined, but studies are underway. Interventions to reverse frailty vary among organ groups and appear promising. This conference achieved its intent to highlight the importance of frailty in organ transplantation and to plant the seeds for further discussion and research in this field.

CoreSlicer: a web toolkit for analytic morphomics

BACKGROUND

Analytic morphomics, or more simply, "morphomics," refers to the measurement of specific biomarkers of body composition from medical imaging, most commonly computed tomography (CT) images. An emerging body of literature supports the use of morphomic markers measured on single-slice CT images for risk prediction in a range of clinical populations. However, uptake by healthcare providers been limited due to the lack of clinician-friendly software to facilitate measurements. The objectives of this study were to describe the interface and functionality of CoreSlicer- a free and open-source web-based interface aiming to facilitate measurement of analytic morphomics by clinicians - and to validate muscle and fat measurements performed in CoreSlicer against reference software.

RESULTS

Measurements of muscle and fat obtained in CoreSlicer show high agreement with established reference software. CoreSlicer features a full set of DICOM viewing tools and extensible plugin interface to facilitate rapid prototyping and validation of new morphomic markers by researchers. We present published studies illustrating the use of CoreSlicer by clinicians with no prior knowledge of medical image segmentation techniques and no formal training in radiology, where CoreSlicer was successfully used to predict operative risk in three distinct populations of cardiovascular patients.

CONCLUSIONS

CoreSlicer enables extraction of morphomic markers from CT images by non-technically skilled clinicians. Measurements were reproducible and accurate in relation to reference software.

Implications of low muscle mass across the continuum of care: a narrative review

Abnormalities in body composition can occur at any body weight. Low muscle mass is a predictor of poor morbidity and mortality and occurs in several populations. This narrative review provides an overview of the importance of low muscle mass on health outcomes for patients in inpatient, outpatient and long-term care clinical settings. A one-year glimpse at publications that showcases the rapidly growing research of body composition in clinical settings is included. Low muscle mass is associated with outcomes such as higher surgical and post-operative complications, longer length of hospital stay, lower physical function, poorer quality of life and shorter survival. As such, the potential clinical benefits of preventing and reversing this condition are likely to impact patient outcomes and resource utilization/health care costs. Clinically viable tools to measure body composition are needed for routine screening and intervention. Future research studies should elucidate the effectiveness of multimodal interventions to counteract low muscle mass for optimal patient outcomes across the healthcare continuum. Key messages Low muscle mass is associated with several negative outcomes across the healthcare continuum. Techniques to identify and counteract low muscle mass in clinical settings are needed.

The Impact of Waiting List BMI Changes on the Short-term Outcomes of Lung Transplantation

BACKGROUND

Obesity and underweight are associated with a higher postlung transplantation (LTx) mortality. This study aims to assess the impact of the changes in body mass index (BMI) during the waiting period for LTx on early postoperative outcomes.

METHODS

Medical records of 502 consecutive cases of LTx performed at our institution between 1999 and 2015 were reviewed. Patients were stratified per change in BMI category between pre-LTx assessment (candidate BMI) and transplant BMI as follows: A-candidate BMI, less than 18.5 or 18.5 to 29.9 and transplant BMI, less than 18.5; B-candidate BMI, less than 18.5 and transplant BMI, 18.5 to 29.9; C-candidate BMI, 18.5 to 29.9 and transplant BMI, 18.5 to 29.9; D-candidate BMI, 30 or greater and transplant BMI, 18.5 to 29.9; and E-candidate BMI, 30 or greater or 18.5 to 29.9 and transplant BMI, 30 or greater. Our primary outcome was in-hospital mortality and secondary outcomes were length of mechanical ventilation, intensive care unit length of stay (LOS), hospital LOS and postoperative complications.

RESULTS

BMI variation during the waiting time was common, as 1/3 of patients experienced a change in BMI category. Length of mechanical ventilation (21 days vs 9 days; P = 0.018), intensive care unit LOS (26 days vs 15 days; P = 0.035), and rates of surgical complications (76% vs 44%; P = 0.018) were significantly worse in patients of group E versus group D. Obese candidates who failed to decrease BMI less than 30 by transplant exhibited an increased risk of postoperative mortality (odds ratio, 2.62; 95% confidence interval, 1.01-6.48) compared with patients in group C. Pre-LTx BMI evolution had no impact on postoperative morbidity and mortality in underweight patients.

CONCLUSIONS

Our results suggest that obese candidates with an unfavorable pretransplant BMI evolution are at greater risk of worse post-LTx outcomes.

Thoracic Skeletal Muscle Is Associated With Adverse Outcomes After Lobectomy for Lung Cancer

BACKGROUND

Assessment of risk associated with lung cancer resection is primarily based on evaluation of cardiopulmonary function and remains imprecise. We investigated the relationship between thoracic muscle and early outcomes after lobectomy.

METHODS

Cross-sectional area of skeletal muscle was measured at the level of the fifth thoracic vertebra on computed tomography in 135 consecutive patients before lobectomy for lung cancer. Patients were stratified into low and high muscle groups using the sex-specific muscle median. Primary outcome was a composite of any postoperative complication as per The Society of Thoracic Surgeons General Thoracic Surgical Database. Secondary outcomes included postoperative respiratory complications, postoperative intensive care unit admission, hospital length of stay, and hospital readmission within 30 days of hospital discharge. The χ² test, adjusted multivariable regression analysis, and likelihood ratio test were performed.

RESULTS

Patients with low muscle were significantly more likely to have any postoperative complication and respiratory postoperative complications. Although postoperative intensive care unit admission was similar for low muscle and high muscle groups, low muscle patients had longer hospital length of stay and a higher rate of hospital readmission. Adjusted multivariable regression revealed the independent association of thoracic muscle with all outcomes. The likelihood ratio test suggested that thoracic muscle adds predictive capability to information captured by preoperative pulmonary function testing.

CONCLUSIONS

Low thoracic muscle is independently associated with increased postoperative complications and health care utilization among patients undergoing lobectomy for lung cancer. Evaluation of thoracic muscle may enhance risk prediction models.

The sarcopenia index: A novel measure of muscle mass in lung transplant candidates

BACKGROUND

Frailty, including low muscle mass, is an emerging risk factor for poor outcomes after lung transplant. The sarcopenia index (SI)-(serum creatinine value/cystatin C value) × 100-is a novel blood test to approximate muscle mass. We sought to validate SI among lung transplant patients.

METHODS

We retrospectively identified adult lung transplant recipients from 2000 through 2012 at our institution who underwent computed tomography within 1 year before transplant and had preserved blood samples. Creatinine and cystatin C values were measured using the samples and used to calculate SI. Muscle mass was estimated by computed tomographic measurement of skeletal muscle cross-sectional surface area (SA) at the L1 to L3 vertebral levels. Correlation between SI and SA was evaluated.

RESULTS

Of 28 patients meeting eligibility criteria, most were white (96%) and men (54%). Median (interquartile range) body mass index, SI, and SA were 25.9 (22-30) kg/m² , 106 (91-119), and 157 (113-195) cm2, respectively. The Pearson correlation coefficient between SI and SA was significant at L2 (0.43; P = .02) and L3 (0.41; P = .03).

CONCLUSION

Sarcopenia index is a potentially objective measure for estimating muscle mass that is noninvasive and less expensive. Sarcopenia index could be considered in lung transplant candidate selection following prospective validation in larger cohorts.

Analytic Morphomics Predict Outcomes After Lung Transplantation

BACKGROUND

The purpose of this study was to identify morphomic factors on standard, pretransplantation computed tomography (CT) scans associated with outcomes after lung transplantation.

METHODS

A retrospective review of 200 patients undergoing lung transplantation at a single institution from 2003 to 2014 was performed. CT scans obtained within 1 year before transplantation underwent morphomic analysis. Morphomic characteristics included lung, dorsal muscle group, bone, and subcutaneous and visceral fat area and density. Patient data were gathered from institutional and United Network for Organ Sharing databases. Outcomes, including initial ventilator support greater than 48 hours, length of stay, and survival, were evaluated using univariate and multivariable analyses.

RESULTS

On multivariable Cox regression, subcutaneous fat/total body area (hazard ratio [HR] 0.60, p = 0.001), lung density 3 volume (HR 0.67, p = 0.013), and creatinine (HR 4.37, p = 0.010) were independent predictors of survival. Initial ventilator support more than 48 hours was associated with decreased vertebral body to linea alba distance (odds ratio [OR] 0.49, p = 0.002) and Zubrod score 4 (OR 14.0, p < 0.001). Increased bone mineral density (p < 0.001) and increased cross-sectional body area (p < 0.001) were associated with decreased length of stay, whereas supplemental oxygen (p < 0.001), bilateral transplantation (p = 0.002), cardiopulmonary bypass (p < 0.001), and Zubrod score 3 (p < 0.001) or 4 (p = 0.040) were associated with increased length of stay.

CONCLUSIONS

Morphomic factors associated with lower metabolic reserve and frailty, including decreased subcutaneous fat, bone density, and body dimensions were independent predictors of survival, prolonged ventilation, and increased length of stay. Analytic morphomics using pretransplantation CT scans may improve recipient selection and risk stratification.

Determinants of pre-transplantation pectoralis muscle area (PMA) and post-transplantation change in PMA in lung transplant recipients

BACKGROUND

This study aimed to determine predictors of pectoralis muscle area (PMA) and assess change in PMA following lung transplantation and its relationship to outcomes.

METHODS

A retrospective review of 88 lung transplant recipients at a single center was performed. PMA was determined on a single axial slice from chest computerized tomography. Pectoralis muscle index (PMI) was calculated from the PMA divided by the height squared.

RESULTS

PMI decreased post-transplantation (8.1±2.8 cm² /m² pre-transplantation, 7.5±2.9 cm² /m² at 6 months, and 7.6±2.7 cm² /m² at 12 months, P<.05). Chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) were predictors of pre-transplant PMI (β=-2.3, P=.001 for COPD; β=2.1, P<.001 for ILD) and percent change in PMI at 12 months post-transplantation relative to baseline (β=19.2, P=.04 for COPD; β=-20.1, P=.01 for ILD). Patients in the highest quartile for PMI change at 12 months had fewer ventilator days compared with patients in the other quartiles (P=.03).

CONCLUSIONS

Underlying diagnosis was a significant predictor of both pre-transplantation PMI and change in PMI post-transplantation. Further studies of PMI are needed to determine its clinical utility in predicting outcomes following lung transplantation.