Sarcopenia defined by psoas muscle index independently predicts long-term survival after living donor liver transplantation in male recipients

Sarcopenia is an independent risk factor for short-term mortality in patients undergoing transjugular intrahepatic portosystemic shunt

BACKGROUND

Sarcopenia is common in patients with cirrhosis and is a risk factor for increased mortality. Transjugular intrahepatic portosystemic shunt (TIPS) placement has been utilized in cirrhosis patients with decompensation. We investigated the role of sarcopenia in predicting mortality in patients undergoing TIPS.

METHODS

We conducted a single-center retrospective study of 232 patients with cirrhosis who underwent TIPS between January 2010 and December 2015. Sarcopenia was defined by the psoas muscle index (PMI) cutoff value, calculated based on dynamic time-dependent outcomes using X-tile software. Kaplan-Meier analysis demonstrated the difference in survival in the sarcopenia group versus the non-sarcopenia group. . Univariate and multivariate analyses were used to identify the relationship between sarcopenia and post-TIPS mortality during a follow-up period of 1 year.

RESULTS

For TIPS indications, 111 (47.84%) patients had refractory ascites, 69 (29.74%) patients had variceal bleeding, 12 (5.17%) patients had ascites, and 40 (17.24%) for other indications. The mean PMI was 4.40 ± 1.55. Sarcopenia was defined as a PMI value of <4.36 in males, and <3.23 in females. Sarcopenia was present in 96 (41.38%) of patients. . Kaplan-Meier analysis showed thatsarcopenia is associated with worse survival (log-rank P < 0.01). Multivariate Cox regression analysis showed that sarcopenia is independently associated with worse survival during the 1-year follow-up period with an hazard ratio of 2.435 (95% CI 1.346-4.403) (P < 0.01), after adjusting for age, BMI, indications for TIPS, etiology for cirrhosis, and MELD score and stratified by sex.

CONCLUSION

Sarcopenia is an independent risk factor for 1-year mortality in patients undergoing TIPS and should be considered when patients are evaluated as a candidate for TIPS.

The clinical significance of sarcopenia in patients with hepatocellular carcinoma treated with lenvatinib and PD-1 inhibitors

Background and aim

Sarcopenia has gained considerable attention in the context of hepatocellular carcinoma, as it has been correlated with a poorer prognosis among patients undergoing sorafenib or lenvatinib treatment for hepatocellular carcinoma (HCC). The clinical significance of sarcopenia in first-line advanced HCC patients treated with lenvatinib and programmed death-1 (PD-1) inhibitors needs to be clarified.

Methods

Sarcopenia was diagnosed using CT (Computed tomography) or MRI (Magnetic Resonance Imaging), with the psoas muscle index (PMI) as the surrogate marker. Patients were grouped based on sarcopenia presences, and a comparative analysis examined characteristics, adverse events, and prognosis. The Cox regression analysis was applied to identify independent prognostic factors for survival, while nomograms were constructed to predict 1-year survival.

Results

Among 180 patients, 46 had sarcopenia. Patients with baseline sarcopenia demonstrated significantly inferior median progression-free survival (mPFS) (3.0 vs. 8.3 months) and median overall survival (mOS) (7.3 vs. 21.6 months). The same results for mPFS (3.3 vs. 9.2 months) and mOS (9.4 vs. 24.2 months) were observed in patients who developed sarcopenia after treatment. Furthermore, significantly higher grade 3 or higher adverse events (AEs) (73.91% vs 41.79%, p<0.001) were recorded in the sarcopenia group compared to the non-sarcopenia group. In the multivariate analysis, distant metastasis, elevated PLR and CRP levels, and low PMI remained independent predictive factors for poor OS. Additionally, skeletal muscle loss remained a significant independent risk factor for PFS. We developed a nomogram incorporating these four indicators, which predicted 12-month survival with a C-index of 0.853 (95% CI, 0.791 - 0.915), aligning well with actual observations.

Conclusion

The prognosis of patients with HCC and sarcopenia is significantly worse when treated with lenvatinib and PD-1 inhibitors. The combination regimen of lenvatinib plus PD-1 inhibitors should be cautiously recommended due to the inferior prognosis and higher AEs.

Prognostic role of sarcopenia on major adverse cardiac events among patients who underwent successful percutaneous coronary intervention: a retrospective cohort study

AIMS

We investigated the prevalence of sarcopenia and its influence on 1-year major adverse cardiac events (MACEs) in patients after successful percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This retrospective medical record review using purposive sampling was conducted at a tertiary care university hospital in Korea. Medical records of a total of 303 patients (≥40 years) who underwent successful PCI between January 2014 and December 2020 were analysed. We retrospectively assessed sarcopenia at initial admission. Sarcopenia was assessed by a sarcopenia index based on a ratio of serum creatinine to serum cystatin C. MACE rates were evaluated within l year after PCI. A Kaplan-Meier analysis with a log-rank test was performed to compare the time with 1-year MACE event-free survival between groups with and without sarcopenia. Cox proportional hazards regression was conducted to assess sarcopenia's influence on MACE. The prevalence of sarcopenia and 1-year MACE after PCI were 24.8 and 8.6%, respectively. We found that sarcopenia at admission (hazard ratio, 3.01; 95% confidence interval, 1.22-7.38, P = 0.017) was significantly associated with 1-year MACE among patients after PCI.

CONCLUSION

Expanding knowledge of sarcopenia among cardiovascular nurses may aid in early recognition of patients at risk of sarcopenia. Our finding implies that the sarcopenia index based on serum creatinine and cystatin C may be available as a prognostic factor for MACE in patients undergoing PCI. Future studies should be conducted to prospectively validate the sarcopenia index with a multi-centre, large sample.

Effect of pretransplant sarcopenia on patient and graft outcomes in solid organ transplant recipients: A systematic review and meta-analysis

The relationship between sarcopenia and prognosis in solid organ transplantation recipients (SOTr) remains unverified. We aimed to quantify the prevalence of pretransplant sarcopenia and its effect on patient and graft survival in SOTr. We used PubMed, EMBASE, Cochrane Library and Web of Science to search relevant studies published in English (from inception to December 31, 2021). Prospective and retrospective cohort studies that reported the prevalence of sarcopenia before transplant or the association between sarcopenia and clinical outcomes in SOTr were included. Primary outcomes were the prevalence of sarcopenia and its impact on patient and graft survival. Secondary outcomes included perioperative complications, acute rejection, length of hospital stay, length of intensive care unit stay (ICU LOS) and early readmission. Thirty-nine studies involving 5792 patients were included. Pooled prevalence of sarcopenia amongst SOTr candidates was 40 % (95 % confidence interval [CI]: 34%-47 % and I2 = 97 %). Sarcopenia was associated with increased risk of death (hazard ratio [HR] = 1.87, 95 % CI: 1.46-2.41 and I2 = 60 %), poor graft survival (HR = 1.71, 95 % CI: 1.16-2.54 and I2 = 57 %) and increased liver graft loss (HR = 1.43, 95 % CI: 1.03-1.99 and I2 = 38 %). Patients with sarcopenia demonstrated increased incidence of perioperative complications (risk ratio [RR] = 1.34, 95 % CI: 1.17-1.53 and I2 = 40 %), long ICU LOS (mean difference = 2.31 days, 95 % CI: 0.58-4.04 and I2 = 97 %) and decreased risk of acute rejection (RR = 0.61, 95 % CI: 0.42-0.89 and I2 = 0 %). In Conclusion, sarcopenia is prevalent in SOTr candidates and associated with death and graft loss. Identifying sarcopenia before transplantation and intervening may improve long-term outcomes.

Sarcopenia increases mortality risk in liver transplantation: a systematic review and meta-analysis

INTRODUCTION

Liver transplantation is an efficacious treatment option for those with liver cirrhosis. However, the prognostic role of sarcopenia in these patients is unknown. Given this background, we conducted a systematic review and meta-analysis of the impact of sarcopenia on mortality in patients listed, evaluated and undergoing liver transplantation.

EVIDENCE ACQUISITION

Several databases were searched from the inception to December 2022 for observational studies regarding sarcopenia in liver transplant and mortality. We calculated the risk of mortality in sarcopenia vs. no sarcopenia using the most adjusted estimate available and summarizing the data as risk ratios (RRs) with their 95% confidence intervals (CIs). A random-effect model was considered for all analyses.

EVIDENCE SYNTHESIS

Among 1135 studies initially considered, 33 articles were included for a total of 12,137 patients (mean age: 55.3 years; 39.4% females). Over a median of 2.6 years and after adjusting for a median of 3 covariates, sarcopenia increased the risk of mortality approximately 2-fold (RR: 2.01; 95% CI: 1.70-2.36). After accounting for publication bias, the re-calculated RR was 1.75 (95% CI: 1.49-2.06). The quality of the studies was generally low, as determined by the Newcastle Ottawa Scale.

CONCLUSIONS

Sarcopenia was significantly linked with an increased risk of mortality in patients listed, evaluated, and undergoing a liver transplantation, indicating the need of interventional studies in this special population with the main aim to reverse this potential reversible condition and decrease mortality risk.

Prevalence and clinical impact of sarcopenia in liver transplant recipients: A meta-analysis

BACKGROUND

The prevalence of sarcopenia in patients undergoing liver transplantation (LT) remains to be determined partly because of different diagnostic criteria. Sarcopenia has recently been recognized as a new prognostic factor for predicting outcomes in LT candidates.

AIM

To estimate the prevalence of sarcopenia and evaluate its clinical effect on LT candidates.

METHODS

This systematic search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for original English-language articles that investigated the prevalence and influence of sarcopenia in patients undergoing LT from database inception to November 30, 2022. Cohort studies of the definition of sarcopenia that estimate sarcopenia prevalence and evaluate its effect on clinical outcomes and the risk of mortality were included.

RESULTS

Twenty-five studies involving 7760 patients undergoing LT were included. The pooled prevalence of sarcopenia in patients undergoing LT was 40.7% [95% confidence intervals (95%CI): 32.1-49.6]. The 1-, 3-, and 5-year cumulative probabilities of post-LT survival in patients with preoperative sarcopenia were all lower than those without sarcopenia (P < 0.05). Sarcopenia was associated with an increased risk of post-LT mortality in patients undergoing LT (adjusted hazard ratio: 1.58; 95%CI: 1.21-2.07). Patients with preoperative sarcopenia had a longer intensive care unit stay, a high risk ratio of sepsis, and serious post-LT complications than those without sarcopenia.

CONCLUSION

Sarcopenia is prevalent in a substantial proportion of patients undergoing LT and is strongly and independently associated with higher a risk of mortality risk.

Ultrasound Evaluation of Sarcopenia in Patients with Hepatocellular Carcinoma: A Faster and Easier Way to Detect Patients at Risk

The condition of sarcopenia, defined as a progressive loss of musculoskeletal mass and muscular strength, is very common in patients with hepatocellular carcinoma (HCC) and presents a remarkable association with its prognosis. Thus, the early identification of sarcopenic patients represents one of the potential new approaches in the global assessment of HCC, and there is increasing interest regarding the potential therapeutic implications of this condition. The gold standard for the quantification of muscle mass is magnetic resonance imaging (MRI) or computed tomography (CT), but these techniques are not always feasible because of the high-cost equipment needed. A new possibility in sarcopenia identification could be muscle ultrasound examination. The measurement of specific parameters such as the muscle thickness, muscular fascicles length or pennation angle has shown a good correlation with CT or MRI values and a good diagnostic accuracy in the detection of sarcopenia. Recently, these results were also confirmed specifically in patients with chronic liver disease. This review summarizes the role of imaging for the diagnosis of sarcopenia in patients with HCC, focusing on the advantages and disadvantages of the diagnostic techniques currently validated for this aim and the future perspectives for the identification of this condition.

Psoas muscle index and psoas muscle density are associated with functional status in patients with degenerative lumbar spinal stenosis

BACKGROUND

The factors affecting lumbar spinal function in patients with degenerative lumbar spinal stenosis (DLSS) are still unclear.

OBJECTIVE

This study explored psoas major muscle morphology in patients with DLSS and its association with their functional status.

METHODS

A retrospective study was conducted on 288 patients with DLSS and 260 control subjects. Psoas major muscle evaluation included three morphometric parameters at the L3/4 disc level: psoas major index (PMI), muscle attenuation, and psoas major morphological changes (MPM). The association between psoas major morphology and functional status was assessed using the Oswestry disability index (ODI).

RESULTS

Both female and male patients with DLSS had a higher PMI and lower muscle attenuation. PMI and muscle attenuation were inversely correlated with age in the DLSS group. After multivariable analyses, the PMI and psoas major muscle attenuation were positively correlated with patients' functional status.

CONCLUSION

The PMI and muscle attenuation were positively correlated with functional status in patients with DLSS. These findings have important implications for physiotherapy programs of postoperative rehabilitation and conservative management of DLSS.

Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis

BACKGROUND

Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties.

METHODS

The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design.

RESULTS

A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001).

CONCLUSION

Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.

Prognostic significance of psoas muscle index in male hepatocellular carcinoma patients treated with immune checkpoint inhibitors and tyrosine kinase inhibitors

Currently, the relationship between nutritional indices and the prognosis of hepatocellular carcinoma (HCC) patients treated with immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) remains unclear. This study aims to investigate the prognostic value of psoas muscle index (PMI), prognostic nutritional index (PNI), body mass index (BMI), and geriatric nutritional risk index (GNRI) in HCC patients treated with ICIs combined with TKIs. A total of 124 male patients with HCC were included in this study. PNI, PMI, BMI, and GNRI were calculated at the beginning of treatment. The Cox proportional hazards model was used to analyze the effect of various variables. In the univariate analysis, PMI, PNI, GNRI, and ALB were found to impact the outcomes of the patients at different follow-up times. However, the predictive value of these nutritional indices was eliminated when established risk factors were considered. In the multivariate analysis that only included nutrition-related indicators, PMI emerged as an independent prognostic factor for 1-year treatment outcomes. The group with low PMI (≤5.5409 cm2/m2) was found to have a higher risk of death at one year and at the end of the follow-up period.

Prevalence of sarcopenia among patients with hepatocellular carcinoma: A systematic review and meta‑analysis

Sarcopenia is a common condition in patients with hepatocellular carcinoma (HCC). Sarcopenia affects the prognosis of patients with HCC and reduces their quality of life. However, to date, there has been no systematic review and meta-analysis to assess the prevalence of sarcopenia in patients with HCC, to the best of our knowledge. PubMed, Embase, Web of Science and the Cochrane Library were comprehensively screened for relevant literature published from March 2001 to June 2022. A random effect analysis was conducted to pool the incidence rates for each study. Subgroup and meta-regression analyses were used to investigate the latent sources of heterogeneities. The Newcastle-Ottawa Scale was used to estimate the quality of the included studies. The I² statistic was used to evaluate heterogeneity between studies. In total, 48 studies encompassing 8,959 patients were included in the meta-analysis. The results of the present meta-analysis showed that nearly half (42%) of the patients with HCC had sarcopenia (95% CI, 0.36-0.48). The morbidity of sarcopenia in studies with a high proportion of males (45%) was higher compared with the morbidity observed in studies with a lower proportion of males (37%). In addition, the incidence rate in younger patients (46%) was found to be higher compared with the incidence rate in older patients (39%). In conclusion, the findings in the present systematic review revealed that a large number of patients with HCC suffer from sarcopenia, indicating the necessity of developing screening and intervention measures to improve the outcome in these patients.

Main factors influencing long-term outcomes of liver transplantation in 2022

Liver transplant (LT) outcomes have markedly improved in the recent decades, even if long-term morbidity and mortality are still considerable. Most of late deaths are independent from graft function and different comorbidities, including complications of metabolic syndrome and de novo neoplasms, seem to play a key role in determining long-term outcomes in LT recipients. This review discusses the main factors associated with late mortality and suggests possible strategies to improve long-term management and follow-up after liver transplantation. In particular, the reduction of drug toxicity, the use of tools to identify high-risk patients, and setting up a multidisciplinary team also for long-term management of LT recipients may further improve survival after liver transplantation.

Association between sarcopenia and clinical outcomes in patients with hepatocellular carcinoma: an updated meta-analysis

Although numerous studies have reported the association between sarcopenia and the prognosis of hepatocellular carcinoma (HCC) patients, there is lack of a newer and more comprehensive meta-analysis. Herein, a comprehensive literature search was performed on PubMed, Web of Science, the Cochrane Library, and Embase databases to identify relevant studies published up to February 2022. The outcomes were overall survival (OS), recurrence, progression-free survival, tumor response, severe postoperative complications, and toxicity of drugs. A total of 57 studies involving 9790 HCC patients were included in the meta-analysis. The pooled prevalence of sarcopenia in HCC patients was 41.7% (95% CI 36.2-47.2%). Results demonstrated that sarcopenia was significantly associated with impaired OS (HR: 1.93, 95% CI 1.73-2.17, P < 0.001), higher risk of tumor recurrence (HR: 1.75, 95% CI 1.56-1.96, P < 0.001), lower objective response rate (OR: 0.37 95% CI 0.17-0.81, P = 0.012), and more drug-related adverse events (OR: 2.23, 95% CI 1.17-4.28, P = 0.015) in HCC patients. The subgroup analyses revealed that the OS of patients at the early stage of tumor was more severely affected by sarcopenia than for patients at other stages. Moreover, the presence of cirrhosis and Child Pugh class B increased the hazard of mortality from sarcopenia. This study has shown that sarcopenia is highly associated with poor prognosis in HCC patients. In addition, cirrhosis and poor liver functional reserve increase the danger of sarcopenia. OS was more impaired in HCC patients with sarcopenia at early stage of tumor than at other tumor stages.

Sarcopenia in the Cirrhotic Patient: Current Knowledge and Future Directions

Cirrhosis predisposes to abnormalities in energy, hormonal, and immunological homeostasis. Disturbances in these metabolic processes create susceptibility to sarcopenia or pathological muscle wasting. Sarcopenia is prevalent in cirrhosis and its presence portends significant adverse outcomes including the length of hospital stay, infectious complications, and mortality. This highlights the importance of identification of at-risk individuals with early nutritional, therapeutic and physical therapy intervention. This manuscript summarizes literature relevant to sarcopenia in cirrhosis, describes current knowledge, and elucidates possible future directions.

Prognostic impact of sarcopenia in patients with hepatocellular carcinoma treated with PD-1 inhibitor

BACKGROUND

Sarcopenia is a progressive generalized loss of skeletal muscle mass commonly observed in advanced stages of cancer.

OBJECTIVE

To assess the relationship between sarcopenia and the prognosis of patients with hepatocellular carcinoma (HCC) treated with a programmed cell death 1 (PD-1) inhibitor.

DESIGN

This is a retrospective study.

METHODS

This study included patients with HCC treated with camrelizumab between 1 March 2020 and 1 December 2021. The skeletal muscle area at the L3 vertebra middle level was used to calculate the skeletal muscle index. Propensity score matching (PSM) analysis was used to balance the variables between the two groups.

RESULTS

In all, 97 patients with HCC were included in the study, with 46 and 51 patients in the sarcopenia group and the non-sarcopenia group, respectively. The baseline characteristics of albumin, Child-Pugh class, albumin-bilirubin score, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio were significantly different between the two groups. In total, 26 patients from each group (n = 52) were selected after the PSM analysis. The progression-free survival (PFS) in the non-sarcopenia group was significantly longer than that in the sarcopenia group before and after PSM analysis (6.5 versus 4.8 months, p = 0.038). In addition, the disease control rate was similar before and after PSM analysis (57.7% versus 69.2%, p = 0.388). The objective response rate in the non-sarcopenia group tended to be higher than that in the sarcopenia group (11.5% versus 30.8%, p = 0.090, after PSM), but no statistically significant difference was found. The median overall survival (OS) in the non-sarcopenia group tended to longer than it in the sarcopenia group before PSM without significant differences (16.3 versus 11.3 months, p = 0.090) and the median OS was similar between the two groups after PSM (16.3 versus 16.8 months, p = 0.735).

CONCLUSIONS

HCC patients with sarcopenia tended to have higher levels of inflammation and lower levels of albumin than patients without sarcopenia. Sarcopenia is associated with a shorter PFS in HCC patients treated with PD-1 inhibitor.

Association between sarcopenia and prognosis of hepatocellular carcinoma: A systematic review and meta-analysis

Background

Sarcopenia, characterized by the loss of muscle mass, strength, and physical ability, occurs with aging and certain chronic illnesses such as chronic liver diseases and cancer. Sarcopenia is common in liver cirrhosis and hepatocellular carcinoma (HCC). Previous reports of association between sarcopenia and prognosis of HCC have been inconsistent. Therefore, the present systematic review and meta-analysis aimed to investigate the impact of sarcopenia on the survival of patients with HCC.

Methods

A systematic literature search was conducted using PubMed, EMBASE, and Web of Science electronic databases from inception to May 1, 2022. We included retrospective or prospective studies investigating the association between sarcopenia and overall survival (OS) and/or progression free survival (PFS) of HCC. We applied the Quality in Prognosis Studies (QUIPS) instrument to evaluate the risk of bias and quality of included studies. The primary and secondary outcomes were the associations of sarcopenia with OS and PFS, respectively, expressed by a pooled hazard ratio (HR) and corresponding 95% confidence interval (CI). Subgroup analysis and sensitivity analysis were performed. We further evaluated the publication bias by the funnel plot and Begg's test.

Results

A total of 42 studies comprising 8,445 patients were included. The majority of included studies were at an overall low risk of bias. The pooled prevalence of sarcopenia was 39% (95% CI: 33-45%) (n = 8,203). Sarcopenia was associated with an increased risk of shorter OS, with a pooled adjusted HR of 1.84 (95% CI: 1.62-2.09). An independent association between sarcopenia and reduced PFS was observed (HR = 1.33, 95% CI: 1.12-1.56).

Conclusion

The prevalence of sarcopenia was approximately 39% among patients with HCC. Sarcopenia was independently associated with reduced OS and PFS in HCC irrespective of treatment modalities. It is imperative that interventions aimed at alleviating sarcopenia and restoring muscle mass be implemented in order to improve the survival of patients with HCC.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022337797], identifier [CRD42022337797].