Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis

Abstract

Background and aims: Obesity is frequently associated with cirrhosis, and cirrhotic patients may develop simultaneous loss of skeletal muscle and gain of adipose tissue, culminating in the condition of sarcopenic obesity. Additionally, muscle depletion is characterized by both a reduction in muscle size and increased proportion of muscular fat, termed myosteatosis. In this study, we aimed to establish the frequency and clinical significance of sarcopenia, sarcopenic obesity and myosteatosis in cirrhotic patients.

Methods: We analysed 678 patients with cirrhosis. Sarcopenia, sarcopenic obesity and myosteatosis were analysed by CT scan using the third lumbar vertebrae skeletal muscle and attenuation indexes, using previously validated gender-and body mass index-specific cutoffs.

Results: Patients were predominately men (n = 457, 67%), and cirrhosis aetiology was hepatitis C virus in 269 patients (40%), alcohol in 153 (23%), non-alcoholic steatohepatitis/cryptogenic in 96 (14%), autoimmune liver disease in 55 (8%), hepatitis B virus in 43 (6%), and others in 5 patients (1%). Sarcopenia was present in 292 (43%), 135 had sarcopenic obesity (20%) and 353 had myosteatosis (52%). Patients with sarcopenia (22 ± 3 vs. 95 ± 22 months, P < 0.001), sarcopenic obesity (22 ± 3 vs. 95 ± 22 months, P < 0.001), and myosteatosis (28 ± 5 vs. 95 ± 22 months, P < 0.001) had worse median survival than patients without muscular abnormalities. By multivariate Cox regression analysis, both sarcopenia [hazard ratio (HR) 2.00, 95% confidence interval (CI) 1.44-2.77, P < 0.001], and myosteatosis (HR 1.42, 95% CI 1.02-1.07, P = 0.04) were associated with mortality.

Conclusions: Sarcopenia, sarcopenic obesity and myosteatosis are often present in patients with cirrhosis, and sarcopenia and myosteatosis are independently associated with a higher long-term mortality in cirrhosis.

Keywords: Cirrhosis; Lumbar skeletal muscle index; Muscle attenuation index; Muscle depletion; Myosteatosis; Overweight.

Figure 1

Venn diagram illustrating the association between sarcopenia, myosteatosis and obesity.

Figure 2

Computed tomography images used for the muscularity assessment of patients with cirrhosis. Comparison of two cirrhotic patients with severe obesity. (A) Male patient at the left had sarcopenic obesity (BMI 47 kg/m², L3 SMI 51 cm²/m²), whereas a female patient at the right (B) had no sarcopenia (BMI 42 kg/m², L3 SMI 49 cm²/m²). Computed tomography images used for the muscle attenuation assessment of patients with cirrhosis and comparison of two cirrhotic patients with similar BMI (28 kg/m²). (C) Patient at the left had low mean muscle attenuation (21 HU), whereas the patient at the right (D) had normal mean muscle attenuation (40 HU).

Figure 3

Kaplan–Meier curve indicating the survival of patients with sarcopenia (—), sarcopenic obesity (‐‐), myosteatosis (‐‐) and without muscular abnormalities (—). The 6‐month probability of survival was 72%, 69%, 76% and 91%, respectively (P < 0.001, log‐rank test). The 1‐year probability of survival was 62%, 59%, 68%, and 85% in these same groups, respectively.

Figure 4

Percentage of mortality related to liver failure, sepsis, hepatocellular carcinoma progression, variceal bleeding, hepatorenal syndrome and others in cirrhotic patients with (A) sarcopenia, (B) myosteatosis and (C) sarcopenic obesity. GI, gastrointestinal; HCC, hepatocellular carcinoma; HRS, hepatorenal syndrome.