Hisaya Shirai

Impact of skeletal muscle mass index, intramuscular adipose tissue content, and visceral to subcutaneous adipose tissue area ratio on early mortality of living donor liver transplantation.

Background Skeletal muscle depletion has been shown to be an independent risk factor for poor survival in various diseases. However, in surgery, the significance of other body components including visceral and subcutaneous adipose tissue remains unclear. Methods This retrospective study included 250 adult patients undergoing living donor liver transplantation (LDLT) between January 2008 and April 2015. Using preoperative plain computed tomography imaging at the third lumbar vertebra level, skeletal muscle mass, muscle quality, and visceral adiposity were evaluated by the skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral to subcutaneous adipose tissue area ratio (VSR), respectively. The cutoff values of these parameters were determined for men and women separately using the data of 657 healthy donors for LDLT between 2005 and 2016. Impact of these parameters on outcomes after LDLT was analyzed. Results VSR was significantly correlated with patient age (P = 0.041), neutrophil-lymphocyte ratio (P < 0.001), body mass index (P < 0.001), and SMI (P = 0.001). The overall survival probability was significantly lower in patients with low SMI (P < 0.001), high IMAC (P < 0.001), and high VSR (P < 0.001) than in each respective normal group. On multivariate analysis, low SMI (hazard ratio [HR], 2.367, P = 0.002), high IMAC (HR, 2.096, P = 0.004), and high VSR (HR, 2.213, P = 0.003) were identified as independent risk factors for death after LDLT. Conclusions Preoperative visceral adiposity, as well as low muscularity, was closely involved with posttransplant mortality.

Proposal of Muscle-MELD score, including muscularity, for prediction of mortality after living donor liver transplantation.

Background The Model for End-stage Liver Diseases (MELD) is currently the most widely accepted scoring system for predicting prognosis and for allocation of liver grafts in patients awaiting liver transplantation (LT). However, this system is independent of the severity of recipient nutritional and functional status. Methods The present study retrospectively evaluated the preoperative quality and quantity of skeletal muscle in 231 adult patients undergoing living donor LT (LDLT) between January 2008 and December 2014. Using plain computed tomography imaging at the third lumbar vertebral level, the preoperative muscularity (quantity and quality of skeletal muscle) was evaluated. We included muscularity with the MELD score (Muscle-MELD) and investigated its ability to predict posttransplant mortality. Results Cox regression analysis provided the following equation for Muscle-MELD: Muscle-MELD = MELD score + 27.0 × low muscle quality + 25.2 × low muscle mass. The overall survival rate after LDLT was significantly lower in patients with high Muscle-MELD than in patients with low Muscle-MELD scores (P < 0.001). Muscle-MELD scores more accurately predicted posttransplant mortality than conventional MELD scores (P = 0.038 for 3 months, P = 0.002 for 6 months, P < 0.001 for 12 months, and P = 0.001 for overall mortality). With multivariate analysis, high Muscle-MELD score was an independent predictor of 6-month mortality after LDLT (odds ratio, 6.715; 95% confidence interval, 3.305-14.653; P < 0.001). Conclusions Muscle-MELD score closely correlates with posttransplant mortality. Our results suggest that perioperative nutritional intervention and rehabilitation would affect posttransplant outcomes with improving pretransplant low muscularity.

Impact of sarcopenic overweight on the outcomes after living donor liver transplantation

Background The effect of body composition disturbances has been recently in focus. Sarcopenic obesity, a co-occurrence of low muscle mass and high body fat was reportedly predictive of high mortality in patients with cirrhosis. However, the impact of the interacting sarcopenia and overweight on the outcomes after liver transplantation is still unclear. Methods We evaluated 200 patients undergoing adult-to-adult living donor liver transplantation at our institution between January 2008 and November 2013 classified according to BMI and psoas muscle index (PMI) on admission to transplant into 4 subgroups; sarcopenic overweight (SO), sarcopenic non-overweight (SN), non-sarcopenic overweight and non-sarcopenic non-overweight (NN). Short-term outcomes and overall post-transplant survival were compared among the four subgroups. Results Sarcopenic patients with preoperative low PMI had higher incidence of postoperative bacteremia and major postoperative complications, and poorer overall post-transplant survival than non-sarcopenic patients with normal/high PMI (P<0.001, respectively). Overweight recipients had a significantly higher overall survival (OS) rate than non-overweight patients (P=0.021). SO subgroup (low PMI and BMI ≥25) had statistically indifferent incidence of postoperative bacteremia, major postoperative complications or overall post-transplant survival than other recipients. In contrast, SN subgroup (low PMI and BMI <25) had higher incidence of postoperative bacteremia (P<0.001), major postoperative complications (P<0.001) than the SO subgroup and possessed the poorest OS among the four recipient subgroups (P=0.001). Conclusions In living donor liver transplantation, preoperative SO did not confer added significant morbidity or mortality risks than the stand-alone sarcopenia.

Preoperative Low Muscle Mass and Low Muscle Quality Negatively Impact on Pulmonary Function in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma

Background: Sarcopenia is a prognostic factor for mortality in digestive surgery. However, the correlation between preoperative cardiopulmonary function and sarcopenia in patients undergoing hepatectomy for hepatocellular carcinoma (HCC) remains unclear. Methods: The present study investigated the impact of preoperative sarcopenia on cardiopulmonary function in 402 patients who underwent first hepatectomy for HCC between April 2005 and April 2015. The quantity and quality of skeletal muscle were evaluated using psoas muscle index (PMI) and intramuscular adipose tissue content (IMAC), respectively, as determined from preoperative computed tomography imaging. Correlations between preoperative cardiopulmonary function and sarcopenic factors (PMI and IMAC) were evaluated. Results: No significant correlations were found between left ventricular ejection fraction and the two sarcopenic factors. On the other hand, preoperative vital capacity (VC) and forced expiratory volume in 1 s (FEV1) correlated significantly with PMI (p < 0.001 each) in males and with IMAC (p < 0.001 each) in females. Moreover, VC and FEV1 in the preoperative low PMI (p < 0.001 each) and high IMAC (p = 0.002 and p < 0.001, respectively) groups were significantly lower than in the normal group in males. In females, VC and FEV1 were significantly lower in the preoperative high IMAC group than in the normal group (p < 0.001 each). Conclusion: Preoperative low muscle mass in males and low muscle quality in males and females were significantly associated with pulmonary dysfunction.

Impact of Sarcopenic Obesity on Outcomes after Liver Transplantation; Does Sarcopenic Obesity cause Poor Prognosis?

Introduction We have reported that sarcopenia is a poor prognostic factor after liver transplantation (LT). However, the significance of sarcopenic obesity is unclear. In this study, we examined the impact of sarcopenic obesity on outcomes after living donor LT (LDLT). Methods We retrospectively analyzed 277 adult patients who underwent LDLT at our institute between January 2008 and June 2016. Using preoperative plain computed tomography imaging at the third lumbar vertebra level, skeletal muscle mass, muscle quality, and visceral adiposity were evaluated by the skeletal muscle mass index (SMI), intramuscular adipose tissue content (IMAC), and visceral to subcutaneous adipose tissue area ratio (VSR), respectively. In this study, we defined low skeletal muscle mass (SMI: male <40.31cm2/m2, female <30.88cm2/m2) and visceral fat area >=100cm2 as sarcopenic obesity. Using this definition, we divided all patients into 4 groups, non-sarcopenic/non-obesity (NN), non-sarcopenic/obesity (NO), sarcopenic/non-obesity (SN), and sarcopenic/obestiy (SO) groups. Overall survivals after LT liver transplantation were compared among the 4 groups Independent risk factors after LT were also analyzed. Results One/five-y OS in patients with of NN group (n=167) were 86%/80%. Compared with NN group, 1/5-y OS in patients of NO (n=55), SN (n=46), and SO (n=9) was 84%/75% (P=0.505), 59%/46% (P<0.001), and 56%/56% (P=0.056), respectively. Multivariate analysis identified low SMI (P=0.020), high IMAC (muscle steatosis) (P<0.001), high VSR (visceral adiposity) (P=0.001), and post-transplant bacteremia (P<0.001) as independent risk factores for death after LT. Conclusion Patients with sarcopenic obesity had worse survival after LDLT. Low muscle mass, muscle steatosis, and visceral adiposity were independent risk factors after LDLT.

Preoperative Visceral Adiposity and Muscularity Predict Poor Outcomes after Hepatectomy for Hepatocellular Carcinoma

Objective: Visceral adiposity, defined as a high visceral-to-subcutaneous adipose tissue area ratio (VSR), has been shown to be associated with poor outcomes in several cancers. However, in the surgical field, the significance of visceral adiposity remains controversial. The present study investigated the impact of visceral adiposity as well as sarcopenic factors (low muscularity) on outcomes in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Patients and Methods: This retrospective study analyzed data from 606 patients undergoing hepatectomy for HCC at our institution between April 2005 and March 2016. Using preoperative plain computed tomography imaging at the level of the third lumbar vertebra, visceral adiposity, skeletal muscle mass, and muscle quality were evaluated by the VSR, skeletal muscle mass index (SMI), and intramuscular adipose tissue content (IMAC), respectively. The impact of these parameters on outcomes after hepatectomy for HCC was analyzed. Results: The overall survival rate was significantly lower among patients with a high VSR (p < 0.001) than among patients with a normal VSR. Similarly, the recurrence-free survival rate was significantly lower among patients with a high VSR (p = 0.016). A high VSR, low SMI, and high IMAC contributed to an increased risk of death (p < 0.001) and HCC recurrence (p < 0.001) in an additive manner. Multivariate analysis showed that not only preoperative low muscularity but also visceral adiposity was a significant risk factor for mortality (hazard ratio [HR] = 1.566, p < 0.001) and HCC recurrence (HR = 1.329, p = 0.020) after hepatectomy for HCC. Conclusions: Preoperative visceral adiposity, as well as low muscularity, was closely related to poor outcomes after hepatectomy for HCC. It is crucial to establish a new strategy including perioperative nutritional interventions with rehabilitation for better outcomes after hepatectomy for HCC.

Proposal for new selection criteria considering pre‐transplant muscularity and visceral adiposity in living donor liver transplantation

The significance of pre‐operative body composition has recently attracted much attention in various diseases. However, cut‐off values for these parameters remain undetermined, and these factors are not currently included in selection criteria for recipients of living donor liver transplantation (LDLT).