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A model including sarcopenia surpasses the MELD score in predicting waiting list mortality in cirrhotic liver transplant candidates: A competing risk analysis in a national cohort
Open accessAbstract
Background & aims Frail patients with low model for end-stage liver disease (MELD) scores may be under-prioritised. Low skeletal muscle mass, namely sarcopenia, has been identified as a risk factor for waiting list mortality. A recent study proposed incorporating sarcopenia in the MELD score (MELD-Sarcopenia score). We aimed to investigate the association between sarcopenia and waiting list mortality, and to validate the MELD-Sarcopenia score (i.e. MELD + 10.35 * Sarcopenia).Methods We identified consecutive patients with cirrhosis listed for liver transplantation in the Eurotransplant registry between 2007-2014 and measured skeletal muscle mass on computed tomography. A competing risk analysis was used to compare survival of patients with and without sarcopenia, and concordance (c) indices were calculated to assess performance of the MELD and MELD-Sarcopenia score. We created a nomogram of the best predictive model.Results We included 585 patients with a median MELD score of 14 (interquartile range 9-19), of which 254 (43.4%) were identified as having sarcopenia. Median waiting list survival was shorter in patients with sarcopenia than those without (p <0.001). This effect was even more pronounced in patients with MELD ≤15. The discriminative performance of the MELD-Sarcopenia score (c-index 0.820) for three-month mortality was lower than MELD score alone (c-index 0.839). Apart from sarcopenia and MELD score, other predictive variables were occurrence of hepatic encephalopathy before listing and recipient age. A model including all these variables yielded a c-index of 0.851.Conclusions Sarcopenia was associated with waiting list mortality in liver transplant candidates with cirrhosis, particularly in patients with lower MELD scores. The MELD-Sarcopenia score was successfully validated in this cohort. However, incorporating sarcopenia in the MELD score had limited added value in predicting waiting list mortality.Lay summary In this study among patients with liver cirrhosis listed for liver transplantation, low skeletal muscle mass was associated with mortality on the waiting list, particularly in patients who were listed with low priority based on a low MELD score. However, adding these measurements to the currently used system for donor and organ allocation showed no added value.
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“Sarcopenia affects 50-60% of individuals 447 and is associated with higher rates of wait-list complications, morbidity, and mortality.”
From EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). (2024) · cites this paper as [448]
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Cites
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Kamath, P. S., & Kim, R. W. (2007) · Hepatology · doi:10.1002/hep.21563 · Cited by 1,674
Hyponatremia and Mortality among Patients on the Liver-Transplant Waiting List
Kim, W. R., Biggins, S. W., Kremers, W. K., Wiesner, R. H., Kamath, P. S., Benson, J. T., Edwards, E. B., & Therneau, T. M. (2008) · New England Journal of Medicine · doi:10.1056/nejmoa0801209 · Cited by 1,485
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Muscle Wasting Is Associated With Mortality in Patients With Cirrhosis
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The new liver allocation system: Moving toward evidence-based transplantation policy
Freeman, R. B., Wiesner, R. H., Harper, A., McDiarmid, S. V., Lake, J., Edwards, E. B., Merion, R. M., Wolfe, R., Turcotte, J. G., & Teperman, L. W. (2002) · Liver Transplantation · doi:10.1053/jlts.2002.35927 · Cited by 724
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Panayotova, G. G., Simonishvili, S., Nguyen, D. T., Graviss, E. A., Aware, N., Manner, C. J., Minze, L. J., Ayorinde, T., Qin, Y., Jin, L., et al. (2024) · Research Square · doi:10.21203/rs.3.rs-2134172/v4
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Reply: Considerations on the use of LPCN 1148 in cirrhotic patients with sarcopenia
Bruno, B. J., Weavil, J. C., Ogle, J., Chidambaram, N., DelConte, A., Patel, M. V., Carey, E. J., Sanyal, A. J., & Lai, J. C. (2025) · Hepatology · doi:10.1097/hep.0000000000001348
Li, Y., Xiang, Y., Yan, X., Lu, C., Huang, J., & Dai, L. (2025) · Open Life Sciences · doi:10.1515/biol-2025-1197
Nouveaux aspects dans la prise en charge de la cirrhose
Weil, D. (2019) · theses.fr (ABES) · doi:10.70675/4a4d8249z67c4z42e5zad08zc3d08f49b5d2
Dave, M., Sathawane, A., Hajare, S., & Khobragade, H. (2026) · Euroasian Journal of Hepato-Gastroenterology · doi:10.5005/jp-journals-10018-1511
Bromfield, B. B., Ruiz‐Margáin, A., Kulik, L., & Duarte‐Rojo, A. (2026) · Current Hepatology Reports · doi:10.1007/s11901-026-00745-7
Metadata
- Authors
- van Vugt, J. L. A., Alferink, L. J. M., Buettner, S., Gaspersz, M. P., Bot, D., Darwish Murad, S., Feshtali, S., van Ooijen, P. M. A., Polak, W. G., Porte, R. J., van Hoek, B., van den Berg, A. P., Metselaar, H. J., & IJzermans, J. N. M.
- Affiliations
- Erasmus MC (NL)
- Leiden University Medical Center (NL)
- University Medical Center Groningen (NL)
- ORCID
- Venue
- Journal of Hepatology
- Publisher
- Elsevier BV
- Published
- 2018-04
- Volume
- 68
- Issue
- 4
- Pages
- 707-714
- ISSN
- 0168-8278 (ISSN-L)
- OpenAlex
- W2772086822
- Cited by
- 208
- References
- 38
- Citations by year
- 2026: 6 · 2025: 16 · 2024: 25 · 2023: 32 · 2022: 31 · 2021: 31 · 2020: 22 · 2019: 31 · 2018: 13
- FWCI
- 11.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Hepatology (publishedVersion)
- PubMed (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (publishedVersion)
- Leiden Repository (Leiden University) (submittedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion, other-oa)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- Funders
- Universiteit Leiden
- Topics
- Health Sciences › Medicine › Hepatology › Liver Disease and Transplantation
- Health Sciences › Medicine › Surgery › Organ Transplantation Techniques and Outcomes
- Health Sciences › Medicine › Physiology (medical) › Nutrition and Health in Aging
- Keywords
- sarcopenia, liver cirrhosis, liver transplantation, waitlist mortality, MELD score, frailty, skeletal muscle mass, hepatic encephalopathy, nomogram, competing risk analysis, recipient age
- MeSH terms
- Female, Humans, Liver Cirrhosis, Male, Middle Aged, Risk, Severity of Illness Index, Waiting Lists, Cohort Studies, Liver Transplantation, Sarcopenia, End Stage Liver Disease
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