title: Inclusion of Sarcopenia Within MELD (MELD-Sarcopenia) and the Prediction of Mortality in Patients With Cirrhosis.
abstract: OBJECTIVE
  Limitations of the Model for End-Stage Liver Disease (MELD) score include its failure to assess the nutritional and functional status of cirrhotic patients. Our objectives were to evaluate the impact of sarcopenia in cirrhosis and whether the inclusion of muscularity assessment within MELD could improve the prediction of mortality in patients with cirrhosis.
  
  
  METHODS
  We included 669 cirrhotic patients who were consecutively evaluated for liver transplantation. Skeletal muscle index at the third lumbar vertebra (L3 SMI) was measured by computed tomography, and sarcopenia was defined using previously published gender and body mass index-specific cutoffs. Using Cox proportional hazards regression, a novel MELD-sarcopenia score was derived.
  
  
  RESULTS
  Sarcopenia was present in 298 patients (45%); sarcopenic patients had shorter median survival than non-sarcopenic patients (20±3 vs. 95±24 months, P<0.001). By Cox regression analysis adjusted for age, gender, and hepatocellular carcinoma, both MELD (hazard ratio (HR) 1.08, 95% confidence interval (CI) 1.06-1.10, P<0.001), and the L3 SMI (HR 0.97, 95% CI 0.96-0.99, P<0.001) were associated with mortality. Overall, the c-statistics for 3-month mortality were 0.82 (95% CI 0.78-0.87) for MELD and 0.85 (95% CI 0.81-0.88) for MELD-sarcopenia (P=0.1). Corresponding figures for 1-year mortality were 0.73 (95% CI 0.69-0.77) and 0.77 (95% CI 0.73-0.80), respectively (P=0.03). The c-statistics for 3-month mortality in patients with MELD<15 (0.85 vs. 0.69, P=0.02) and refractory ascites (0.74 vs. 0.71, P=0.01) were significantly higher for MELD-sarcopenia compared with MELD.
  
  
  CONCLUSIONS
  Modification of MELD to include sarcopenia is associated with improved prediction of mortality in patients with cirrhosis, primarily in patients with low MELD scores. External validation of this prognostic index in larger cohorts of cirrhotic patients is warranted.
authors.affiliation: Division of Gastroenterology and Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada.
authors.forename: Aldo J
authors.initials: AJ
authors.lastname: Montano-Loza
authors.affiliation: Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
authors.forename: Andres
authors.initials: A
authors.lastname: Duarte-Rojo
authors.affiliation: Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada.
authors.forename: Judith
authors.initials: J
authors.lastname: Meza-Junco
authors.affiliation: Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada.
authors.forename: Vickie E
authors.initials: VE
authors.lastname: Baracos
authors.affiliation: Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Sawyer
authors.affiliation: 1] Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada [2] Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Jack X Q
authors.initials: JX
authors.lastname: Pang
authors.affiliation: Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada.
authors.forename: Crystal
authors.initials: C
authors.lastname: Beaumont
authors.affiliation: Department of Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada.
authors.forename: Nina
authors.initials: N
authors.lastname: Esfandiari
authors.affiliation: 1] Liver Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada [2] Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Myers