Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score

Abstract

Background: Although malnutrition and sarcopenia are prevalent in cirrhosis, their impact on outcomes following liver transplantation is not well documented.

Methods: The associations of nutritional status and sarcopenia with post-transplant infections, requirement for mechanical ventilation, intensive care (ICU) and hospital stay, and 1 year mortality were assessed in 232 consecutive transplant recipients. Nutritional status and sarcopenia were assessed using the Royal Free Hospital-Global Assessment (RFH-GA) tool and the L3-psoas muscle index (L3-PMI) on CT, respectively.

Results: A wide range of RFH-SGA and L3-PMI were observed within similar Model for End-stage Liver Disease (MELD) sub-categories. Malnutrition and sarcopenia were independent predictors of all outcomes. Post-transplant infections were associated with MELD (OR = 1.055, 95%CI = 1.002-1.11) and severe malnutrition (OR = 6.55, 95%CI = 1.99-21.5); ventilation > 24 h with MELD (OR = 1.1, 95%CI = 1.036-1.168), severe malnutrition (OR = 8.5, 95%CI = 1.48-48.87) and suboptimal donor liver (OR = 2.326, 95%CI = 1.056-5.12); ICU stay > 5 days, with age (OR = 1.054, 95%CI = 1.004-1.106), MELD (OR = 1.137, 95%CI = 1.057-1.223) and severe malnutrition (OR = 7.46, 95%CI = 1.57-35.43); hospital stay > 20 days with male sex (OR = 2.107, 95%CI = 1.004-4.419) and L3-PMI (OR = 0.996, 95%CI = 0.994-0.999); 1 year mortality with L3-PMI (OR = 0.996, 95%CI = 0.992-0.999). Patients at the lowest L3-PMI receiving suboptimal grafts had longer ICU/hospital stay and higher incidence of infections.

Conclusions: Malnutrition and sarcopenia are associated with early post-liver transplant morbidity/mortality. Allocation indices do not include nutritional status and may jeopardize outcomes in nutritionally compromised individuals.

Keywords: Cirrhosis; Morbidity; Mortality; Nutritional assessment; Prognosis.

Figure 1

Box plots of L3‐psoas muscle index (L3‐PMI) for male and female patients stratified according to Royal Free Hospital‐Global Assessment (RFH‐GA). Males well‐nourished: median PMI = 492.7 (range 224.2–856.1), mild/moderately malnourished: median PMI = 399.05.4 (187.3–648.7), severely malnourished: median PMI = 313.5 (195.8–454.9). Females well‐nourished: median PMI = 388.8 (range 210.4–763.8), mild/moderately malnourished: median PMI = 309.4 (78.9–589.9), severely malnourished: median PMI = 317.65 (215.8–508.1).

Figure 2

Box‐plots of L3‐psoas muscle index (L3‐PMI) for male and female patients stratified according to Model for End‐stage Liver Disease (MELD). Males: median L3‐PMI levels were 486.6 (range 200.8–856.1), 417.6 (178.9–817.3), 415.15 (236.7–806.2), 335.6 (187.3–536.2), and 483.2 (162.5–983) mm²/m² for MELD score ≤10, 11–15, 16–20, 21–25, and >25, respectively. Females: median L3‐PMI levels were 370.5 (range 78.9–554.6), 330.75 (135.4–589.9), 368.3 (150.5–763.8), 308 (205.4–392.3), and 359.9 (215.8–394.9) mm²/m² for MELD score ≤10, 11–15, 16–20, 21–25, and >25, respectively.

Figure 3

Nutritional status of the transplant recipients assessed by Royal Free Hospital‐Global Assessment (RFH‐GA) stratified according to Model for End‐stage Liver Disease (MELD) score.