LIVER TRANSPLANTATION 20:1423, 2014
LETTER TO THE EDITORS
Sarcopenia and Survival After Liver Transplantation Received July 7, 2014; accepted July 7, 2014.
TO THE EDITORS: We are very interested in the work of Montano-Loza et al.1 examining the impact of sarcopenia on the postoperative stay and survival after liver transplantation (LT). However, there may be some confounders on which, because of the nature of the study, the authors were unable to comment. First, the doctors have included only patients who went on to receive LT. This could have introduced a selection bias because many patients who could have had sarcopenia might not have been listed. Thus, only those patients deemed fit for LT would have been included; this might explain why the overall impact of sarcopenia was not too dramatic. It would also have been interesting to know what proportion of sarcopenic patients had supplemental feeding such as nasogastric feeding. This could have helped the overall nutritional status of the patient, maintained gut wall integrity, and reduced the endotoxin load to the liver; this has been proved to occur in the setting of acute or chronic liver failure and decompensation, including spontaneous bacterial peritonitis and hepatorenal syndrome.2 Moreover, did the sarcopenic patients who had supplemental feeding do better than those who did not? Finally, we agree with the authors that the current methods used to assess liver disease severity (eg, Model for End-Stage Liver Disease) might disadvantage some patients and do not give a functional assessment of a patient’s fitness for major surgery. Methods such as cardiopulmonary exercise testing are being used in some centers to determine a patient’s preoperative and postoperative survival.3-5 An assessment of sarcopenia by computer tomography techniques or a functional assessment by
hand-grip strength may complement dynamic assessments such as cardiopulmonary exercise testing as well as existing hepatological models to better identify those patients who are likely to benefit as well as those who are likely to be disadvantaged by LT. The work of Montano-Loza et al. is, therefore, a useful contribution to this goal. Katie Clark, M.D. Tim Cross, M.D. Department of Hepatology Royal Liverpool Hospital Liverpool, England
REFERENCES 1. Montano-Loza AJ, Meza-Junco J, Baracos VE, Prado CM, Ma M, Meeberg G, et al. Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl 2014; 20:640-648. 2. Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, et al. Bacterial infections in cirrhosis: a position statement based on the EASL special conference 2013. J Hepatol 2014;60:1310-1324. 3. Prentis JM, Manas DM, Trenell MI, Hudson M, Jones DJ, Snowden CP. Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation. Liver Transpl 2012;18:152-159. 4. Bernal W, Martin-Mateos R, Lipcsey M, Tallis C, Woodsford K, McPhail MJ, et al. Aerobic capacity during cardiopulmonary exercise testing and survival with and without liver transplantation for patients with chronic liver disease. Liver Transpl 2014;20:54-62. 5. Ow MM, Erasmus P, Minto G, Struthers R, Joseph M, Smith A, et al. Impaired functional capacity in potential liver transplant candidates predicts short-term mortality before transplantation. Liver Transpl 2014:20;1081–1088.
Address reprint requests to Katie Clark, M.D., Department of Hepatology, Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP England. E-mail: [email protected] DOI 10.1002/lt.23959 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
LETTER TO THE EDITORS
Sarcopenia and Survival After Liver Transplantation Received July 7, 2014; accepted July 7, 2014.
TO THE EDITORS: We are very interested in the work of Montano-Loza et al.1 examining the impact of sarcopenia on the postoperative stay and survival after liver transplantation (LT). However, there may be some confounders on which, because of the nature of the study, the authors were unable to comment. First, the doctors have included only patients who went on to receive LT. This could have introduced a selection bias because many patients who could have had sarcopenia might not have been listed. Thus, only those patients deemed fit for LT would have been included; this might explain why the overall impact of sarcopenia was not too dramatic. It would also have been interesting to know what proportion of sarcopenic patients had supplemental feeding such as nasogastric feeding. This could have helped the overall nutritional status of the patient, maintained gut wall integrity, and reduced the endotoxin load to the liver; this has been proved to occur in the setting of acute or chronic liver failure and decompensation, including spontaneous bacterial peritonitis and hepatorenal syndrome.2 Moreover, did the sarcopenic patients who had supplemental feeding do better than those who did not? Finally, we agree with the authors that the current methods used to assess liver disease severity (eg, Model for End-Stage Liver Disease) might disadvantage some patients and do not give a functional assessment of a patient’s fitness for major surgery. Methods such as cardiopulmonary exercise testing are being used in some centers to determine a patient’s preoperative and postoperative survival.3-5 An assessment of sarcopenia by computer tomography techniques or a functional assessment by
hand-grip strength may complement dynamic assessments such as cardiopulmonary exercise testing as well as existing hepatological models to better identify those patients who are likely to benefit as well as those who are likely to be disadvantaged by LT. The work of Montano-Loza et al. is, therefore, a useful contribution to this goal. Katie Clark, M.D. Tim Cross, M.D. Department of Hepatology Royal Liverpool Hospital Liverpool, England
REFERENCES 1. Montano-Loza AJ, Meza-Junco J, Baracos VE, Prado CM, Ma M, Meeberg G, et al. Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation. Liver Transpl 2014; 20:640-648. 2. Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, et al. Bacterial infections in cirrhosis: a position statement based on the EASL special conference 2013. J Hepatol 2014;60:1310-1324. 3. Prentis JM, Manas DM, Trenell MI, Hudson M, Jones DJ, Snowden CP. Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation. Liver Transpl 2012;18:152-159. 4. Bernal W, Martin-Mateos R, Lipcsey M, Tallis C, Woodsford K, McPhail MJ, et al. Aerobic capacity during cardiopulmonary exercise testing and survival with and without liver transplantation for patients with chronic liver disease. Liver Transpl 2014;20:54-62. 5. Ow MM, Erasmus P, Minto G, Struthers R, Joseph M, Smith A, et al. Impaired functional capacity in potential liver transplant candidates predicts short-term mortality before transplantation. Liver Transpl 2014:20;1081–1088.
Address reprint requests to Katie Clark, M.D., Department of Hepatology, Royal Liverpool Hospital, Prescot Street, Liverpool, L7 8XP England. E-mail: [email protected] DOI 10.1002/lt.23959 View this article online at wileyonlinelibrary.com. LIVER TRANSPLANTATION. DOI 10.1002/lt. Published on behalf of the American Association for the Study of Liver Diseases
C 2014 American Association for the Study of Liver Diseases. V
