Yuhei Hamaguchi

Impact of quality as well as quantity of skeletal muscle on outcomes after liver transplantation

Intramuscular fat accumulation has come to be associated with loss of muscle strength and function, one of the components of sarcopenia. However, the impact of preoperative quality of skeletal muscle on outcomes after living donor liver transplantation (LDLT) is unclear. The present study evaluated the intramuscular adipose tissue content (IMAC) and psoas muscle mass index (PMI) in 200 adult patients undergoing LDLT at our institution between January 2008 and October 2013. Correlations of IMAC with other factors, overall survival rates in patients classified according to IMAC or PMI, and risk factors for poor survival after LDLT were analyzed. IMAC was significantly correlated with age (r = 0.229, P = 0.03) and PMI (r = −0.236, P = 0.02) in males and with age (r = 0.349, P < 0.001) and branched‐chain amino acid (BCAA)‐to‐tyrosine ratio (r = −0.250, P = 0.01) in females. The overall survival rates in patients with high IMAC or low PMI were significantly lower than those for patients with normal IMAC or PMI (P < 0.001, P < 0.001, respectively). Multivariate analysis showed that high IMAC [odds ratio (OR) = 3.898, 95% confidence interval (CI) = 2.025‐7.757, P < 0.001] and low PMI (OR = 3.635, 95% CI = 1.896‐7.174, P < 0.001) were independent risk factors for death after LDLT. In conclusion, high IMAC and low PMI were closely involved with posttransplant mortality. Preoperative quality and quantity of skeletal muscle could be incorporated into new selection criteria for LDLT. Perioperative nutritional therapy and rehabilitation could be important for good outcomes after LDLT. Liver Transpl 20:1413‐1419, 2014.

Impact of preoperative quality as well as quantity of skeletal muscle on survival after resection of pancreatic cancer

BACKGROUND Skeletal muscle depletion, referred to as sarcopenia, is predictive of mortality in patients undergoing digestive operations. The impact of muscle quality on outcomes, however, is unclear. This retrospective study investigated the impact of preoperative skeletal muscle quantity and quality on survival in patients undergoing resection of pancreatic cancer. METHODS We investigated 230 patients who underwent resection of pancreatic cancer between 2004 and 2013. The quantity and quality of skeletal muscle, indicated by psoas muscle mass index (PMI) and intramuscular adipose tissue content (IMAC), were measured in preoperative computed tomography images. Overall survival (OS) and recurrence-free survival (RFS) rates were compared according to PMI and IMAC, and prognostic factors after pancreatic resection were assessed. RESULTS The OS and RFS rates in patients with low PMI were lesser than in those with normal/high PMI (P < .001, P < .001), with a mean survival time of 17.7 and 33.2 months, respectively. The OS and RFS rates in patients with high IMAC also were less than in those with normal/low IMAC (P < .001, P = .003) (mean survival time = 21.5 and 56.5 months, respectively). Low PMI (low muscle mass) and high IMAC (low muscle quality) were independent prognostic factors of poor OS (hazard ratio [HR] = 1.999, P < .001; HR = 2.527, P < .001) and RFS (HR = 1.607, P = .007; HR = 1.640, P = .004), respectively. CONCLUSION Preoperative sarcopenia, indicating low quality and quantity of skeletal muscle, is closely related to mortality after resection of pancreatic cancer.

Preoperative intramuscular adipose tissue content is a novel prognostic predictor after hepatectomy for hepatocellular carcinoma

Sarcopenia has been shown to be an independent predictor of lower disease‐free and overall survival in various kinds of diseases. The quality of skeletal muscle has recently attracted much attention as a new parameter of sarcopenia.

Impact of the preoperative quantity and quality of skeletal muscle on outcomes after resection of extrahepatic biliary malignancies

BACKGROUND Skeletal muscle depletion, referred to as sarcopenia, predicts mortality after major surgery. This study investigated the impact of preoperative skeletal muscle quantity and quality on outcomes in patients undergoing resection of extrahepatic biliary cancer. METHODS We performed a retrospective analysis of 207 patients undergoing resection for biliary cancer between 2004 and 2013. The quantity and quality of skeletal muscle, indicated by the psoas muscle mass index (PMI) and intramuscular adipose tissue content (IMAC), were measured on preoperative images of computed tomography. Overall survival (OS) and recurrence-free survival (RFS) rates were compared by PMI and IMAC, and prognostic factors after operation were assessed. RESULTS The OS and RFS rates were less in patients with low PMI (low muscle quantity) than in those with normal PMI (P < .001 and P < .001; 5-year OS, 15.7 vs 53.5%). The OS and RFS rates were also less in patients with high IMAC (low muscle quality) than in those with normal IMAC (P < .001 and P < .001; 5-year OS, 23.8 vs 55.9%). Low PMI and high IMAC were independent factors predictive of poor OS (hazard ratio [HR], 2.921 [95% CI, 1.920-4.470; P < .001] and HR, 1.725 [95% CI, 1.159-2.590; P = .007]) and RFS (HR, 2.141 [95% CI, 1.464-3.129, P < .001] and HR, 1.492 [95% CI, 1.032-2.166, P = .034]). CONCLUSION Preoperative sarcopenia, indicating a low quantity and quality of skeletal muscle, is related closely to mortality after resection of biliary cancer.

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.

Impact of postoperative changes in sarcopenic factors on outcomes after hepatectomy for hepatocellular carcinoma.

We have reported that preoperative low skeletal muscle quality was an independent risk factor for poor outcomes after hepatectomy for hepatocellular carcinoma (HCC). However, postoperative changes of quality as well as quantity of skeletal muscle after hepatectomy for HCC and their impact on postoperative outcomes have not been fully investigated.

Incidence and risk factors for herpes zoster in patients undergoing liver transplantation

Herpes zoster (HZ) is the most common manifestation of latent varicella zoster virus reactivation, which occurs naturally as a result of aging or in immunocompromised patients. Solid organ transplant recipients are at increased risk for HZ owing to their chronic immunosuppression. Although several reports investigated risk factors for the development of HZ in heart or renal transplantation, data in liver transplantation (LT) are limited.

Evaluation of safety of concomitant splenectomy in living donor liver transplantation: a retrospective study

In Asian countries, concomitant splenectomy in living donor liver transplantation (LDLT) is indicated to modulate the portal vein pressure in the small‐sized graft to protect against small for size syndrome. While concomitant splenectomy in deceased donor liver transplantation is almost contraindicated based on Western Reports of increased mortality and morbidity rate due to septic complications, there are few studies about that in LDLT. So, we retrospectively investigated the clinical outcome of adult LDLT at Kyoto University Hospital from July 2010 to July 2016. We divided the patients (n = 164) into those with concomitant splenectomy (n = 88) and those without (n = 76). The splenectomy group showed significantly increased operative time and intraoperative blood loss (P = 0.008, P = 0.0007, respectively), and significantly higher rate of postoperative splenic vein thrombosis and cytomegalovirus infection (P = 0.03, P = 0.016, respectively). However, there were no significant differences between the two groups regarding the incidence of postoperative hemorrhage (P = 0.06), post‐transplant bacteremia (P = 0.38), infection‐related mortality rates (P = 0.8), acute rejection (P = 0.87), and patient and graft survival (P = 0.66, P = 0.67 respectively); finally, model for end‐stage liver disease score above 30 was an independent predictor for infection‐related mortality post‐transplant (HR = 5.99, 95% CI = 2.15–16.67, P = 0.001). In conclusion, concomitant splenectomy in LDLT can be safely performed when indicated.

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.