L3 SMI Research Articles

Cystatin C and Sarcopenia Predict Acute on Chronic Liver Failure Development and Mortality in Patients on the Liver Transplant Waiting List.

Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.

Prognostic value of the third lumbar skeletal muscle mass index in patients with liver cirrhosis and ascites.

The objective nutritional assessment indicators, body mass index (BMI), upper arm muscle circumference (MAMC), and triceps skinfold thickness (TSF), are often limited due to ascites. This study investigated the prognostic value of the third lumbar vertebrae skeletal muscle mass index (L3 SMI) in addition to the objective nutritional evaluation indicators (BMI, MAMC and TSF) in patients with liver cirrhosis and ascites. In this retrospective analysis, a total of 147 patients with liver cirrhosis and ascites were included. The L3 SMI, BMI, MAMC and TSF were detected in all patients. The severity of liver disease was assessed by the Model End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) classification. These variables were compared between non-surviving and surviving patients who were classified according to 5-year mortality. Of the 147 patients, 62 (42.2%) died and 85 (57.8%) survived within 5 years. The L3 SMI of patients was significantly lower than that of the normal control group (39.58±7.18cm2/m2 vs. 53.73±7.92cm2/m,2p<0.001). The L3 SMI (OR 4.02; 95% CI 2.17-9.63; p<0.001), MELD score (OR 2.11; 95% CI 1.12-4.13; p<0.001) and CTP class (OR 2.69; 95% CI 1.09-5.06; p<0.001) were independent predictive indicators of 5-year mortality. Furthermore, the performance of the two variables (L3 SMI and MELD) together (AUROC: 0.812) was significantly better than that of MELD alone (AUROC: 0.787) for prediction of 5-year mortality (p<0.001). Compared with MAMC, TSF and BMI, L3 SMI is an independent risk factor for 5-year mortality in patients with liver cirrhosis and ascites. Further nutritional intervention studies are needed to confirm the impact of the L3 SMI index on clinical outcomes.

Low muscle mass is associated with early termination of chemotherapy related to toxicity in patients with head and neck cancer

We studied whether low pre-treatment muscle mass, measured with CT at thoracic (T4) or lumbar level (L3) associates with early termination of chemotherapy related to toxicity in head and neck cancer (HNC) patients. This was a retrospective chart and image review. Adult HNC patients treated with (surgery and) platinum-based chemo-radiotherapy were included if a pre-treatment CT scan at T4 or L3 level was available. Muscle mass was evaluated by assessment of skeletal muscle index (SMI; cm2/m2). T4 and L3 SMI measurements were corrected for deviation from their respective means and were merged into one score for SMI difference (cm2/m2). All cases were assessed for presence of toxicity-related unplanned early termination of chemotherapy ('early termination'). Univariate and multivariate logistic regression models were used to investigate associations between pooled SMI and early termination. 213 patients (age: 57.9±10.3y, male: 77%, T4 image: 45%) were included. A significant association between SMI as a continuous variable and early termination was found, both in the univariate analysis (p=0.007, OR=0.96 [0.94-0.99]) and the multivariate analysis (p=0.021, OR 0.96 [0.92-0.99]). The multivariate models identified potential associations with type of chemotherapy, presence of co-morbidity, a combination of (former) smoking and alcohol consumption, and sex. Lower muscle mass was robustly associated with higher odds of early termination of chemotherapy in HNC patients. Further prospective studies are required to tailor the care for patients with low muscle mass and to avoid early termination of chemotherapy.

Rapidly declining skeletal muscle mass predicts poor prognosis of hepatocellular carcinoma treated with transcatheter intra-arterial therapies

BackgroundThe impact of sarcopenia on the prognosis of patients with hepatocellular carcinoma (HCC) who receive transcatheter intra-arterial therapies, including transcatheter arterial chemoembolization and transcatheter arterial infusion chemotherapy, remains unclear. We investigated the prognostic value of skeletal muscle loss (SML) stratified by cutoffs for sarcopenia and rate of change in skeletal muscle mass over 6 months.MethodsWe retrospectively evaluated 102 patients with HCC treated with transcatheter intra-arterial therapies between 2005 and 2015. Computed tomography images of the third lumbar vertebra (L3) were analyzed to obtain the skeletal muscle area normalized for the height squared, defined as the skeletal muscle index at L3 (L3 SMI), before and 6 months after treatment. Low or high SMI was defined using cutoff values of 42 cm2/m2 in men and 38 cm2/m2 in women. The rate of change in skeletal muscle mass (ΔL3 SMI) over 6 months was calculated. Overall survival (OS) was compared in groups classified by baseline L3 SMI and ΔL3 SMI; prognostic significance was assessed with univariate and multivariate analyses, using Cox proportional hazards models.ResultsOS did not differ significantly between groups with low (n = 31) and high (n = 71) SMI at baseline (P = 0.172), but OS was significantly poorer in patients with SML (n = 41), defined as ΔL3 SMI < − 4.6% over 6 months than in those without SML (n = 61, P = 0.018). On multivariate analysis, SML (hazard ratio [HR], 1.675; 95% confidence interval [CI], 1.031–2.721; P = 0.037), serum alpha-fetoprotein ≥20 ng/mL (HR, 2.550; 95% CI, 1.440–4.515; P = 0.001), and maximum tumor diameter ≥ 30 mm (HR, 1.925; 95% CI, 1.166–3.179; P = 0.010) were independent predictors of poor OS. Baseline L3 SMI was not significantly associated with OS (HR, 1.405; 95% CI, 0.861–2.293; P = 0.174).ConclusionsΔL3 SMI was an independent prognostic factor in patients with HCC treated with transcatheter intra-arterial therapies. Further study is required to reveal whether prevention of skeletal muscle depletion might be a new therapeutic strategy to contribute to improved clinical outcomes in patients with HCC.

Can sarcopenia be a predictor of prognosis for patients with non-metastatic colorectal cancer? A systematic review and meta-analysis.

We aimed to explore whether sarcopenia diagnosed with the third lumbar vertebra skeletal muscle index (L3 SMI) can be a predictor of prognosis for colorectal cancer (CRC) patients. A systematic review and meta-analysis was conducted using PubMed, Embase, and the Web of Science databases. All original comparative studies published in English that were related to sarcopenia versus non-sarcopenia in non-metastatic CRC patients based on postoperative and survival outcomes were included. Data synthesis and statistical analysis were carried out using Stata software. A total of 12 studies including 5337 patients were included in our meta-analysis. In our overall analyses of postoperative outcomes, we indicated that CRC patients with sarcopenia would have longer hospital stays, higher incidence of total postoperative morbidity (OR = 1.70, 95% CI = 1.07-2.70, P < 0.01), mortality (OR = 3.45, 95% CI = 1.69-7.02, P < 0.01), and infection (OR = 2.21, 95% CI = 1.50-3.25, P < 0.01) but not anastomosis leakage or intestinal obstruction when compared to non-sarcopenia patients. Regarding survival outcomes, our results showed that sarcopenia predicted a decreased overall survival (HR = 1.63, 95% CI = 1.24-2.14, P < 0.01), disease-free survival, and cancer-specific survival for non-metastatic CRC patients. Moreover, our subgroup analyses showed similar tendency with our overall analyzed results. Sarcopenia diagnosed with L3 SMI can be a negative predictor of postoperative and survival outcomes for non-metastatic CRC patients. Prospective studies with a uniform definition of sarcopenia are needed to update our findings.

Association between Low Testosterone Levels and Sarcopenia in Cirrhosis: A Cross-sectional Study

Introduction and aim. Sarcopenia is an independent predictor of mortality in cirrhosis. Hypogonadism is common in cirrhosis and has been associated with sarcopenia in non-cirrhotic chronic liver disease populations. The aim of this study is to investigate if sarcopenia is associated with low testosterone levels in patients with cirrhosis.Material and methods. This is a retrospective analysis of prospectively collected data of 211 cirrhotic patients undergoing evaluation for liver transplantation. Sarcopenia was defined by computed tomography (CT) scan using specific cutoffs of the 3rd lumbar vertebra skeletal muscle index (L3 SMI). Morning testosterone levels were obtained in all patients.Results. Of the 211 patients, sarcopenia was noted in 94 (45%). Testosterone levels were lower in sarcopenic patients (10.7 ± 1.1 vs. 13.7 ± 1.4 nmol/L, p = 0.03) and hypotestosteronemia was more frequent in them too (34 vs. 16%, p = 0.004). In males, those with sarcopenia had lower testosterone levels (14.6 ± 1.4 vs. 21.9 ± 1.8, p = 0.002), and the corresponding frequency of hypotestosteronemia (42 vs. 19%, p = 0.006) was also higher. There were no significant differences in female patients. There was a weak correlation between L3 SMI and testosterone levels (r 0.37, p < 0.001). On multivariable regression analysis including sex, body mass index (BMI), hypotestosteronemia, MELD and etiology of cirrhosis, only hypotestosteronemia (RR 2.76, p = 0.005) and BMI (RR 0.88, p < 0.001) were independently associated with sarcopenia.Conclusion. Low testosterone levels are associated with sarcopenia in male cirrhotic patients. The potential therapeutic effect of testosterone to reverse sarcopenia in these patients warrants evaluation in future trials.

Study of the Correlation between Serum Testosterone Level and Sarcopenia in Egyptian Male Patients with Liver Cirrhosis

Background and study aim: Irrespective of etiology, liver cirrhosis together with its complications can affect other body organs and lead to a great morbidity and mortality. In Cirrhotic patients, Sarcopenia block normal life activities. Low serum testosterone has been reported in up to 90% of men with liver cirrhosis. This study aimed to assess the correlation between serum testosterone level and sarcopenia in Egyptian male patients with liver cirrhosis. Patients and Methods: This prospective study included sixty cirrhotic males. Three groups were designed according to Child-Pugh classification. Twenty healthy males were included as control group. Patients and controls were subjected to complete blood picture, liver and kidney functions. Serum total & free testosterone was analyzed by specific enzyme-linked immunosorbent assay (ELISA) kit and Skeletal Muscle Index (L3 SMI) was assessed by CT scan. Results: There was significant decrease in serum levels of free and total testosterone in cirrhotic patients than controls, with lowest levels in child C cirrhotic males (p value <0.001). 32 (53.3%) cirrhotic patients were sarcopenic‏.‏ At cutoff point 14.1 nmol/L total testosterone level has Sensitivity 91%, Specificity 94% and Accuracy 93.0% to predict sarcopenia in cirrhotic males with AUC = 0.938. There was significant positive correlation between total testosterone level and the L3 SMI (r= 0.819, P<0.001). In addition, a positive correlation was detected between total testosterone and hemoglobin (r= 0.668, P<0.001), serum Na (r= 0.846, P<0.001) and Platelet count (r= 0.904, P<0.001), also negative correlation with MELD score (r= - 0.928, P<0.001). Conclusion: Significant positive correlation between total testosterone level and Skeletal Muscle Index (L3 SMI) and low testosterone level is associated with sarcopenia in cirrhotic males.

Lumbar skeletal muscle index derived from routine computed tomography exams predict adverse post-extubation outcomes in critically ill patients

PurposeTo evaluate the effect of a skeletal muscle index derived from a routine CT image at the level of vertebral body L3 (L3SMI) on outcomes of extubated patients in the surgical intensive care unit. Materials and methods231 patients of a prospective observational trial (NCT01967056) who had undergone CT within 5days of extubation were included. L3SMI was computed using semi-automated segmentation. Primary outcomes were pneumonia within 30days of extubation, adverse discharge disposition and 30-day mortality. Secondary outcomes included re-intubation within 72h, total hospital costs, ICU length of stay (LOS), post-extubation LOS and total hospital LOS. Outcomes were analyzed using multivariable regression models with a priori-defined covariates height, gender, age, APACHE II score and Charlson Comorbidity Index. ResultsL3SMI was an independent predictor of pneumonia (aOR 0.96; 95% CI 0.941–0.986; P=0.002), adverse discharge disposition (aOR 0.98; 95% CI 0.957–0.999; P=0.044) and 30-day mortality (aOR 0.94; 95% CI 0.890–0.995; P=0.033). L3SMI was significantly lower in re-intubated patients (P=0.024). Secondary analyses suggest that L3SMI is associated with total hospital costs (P=0.043) and LOS post-extubation (P=0.048). ConclusionThe lumbar skeletal muscle index, derived from routine abdominal CT, is an objective prognostic tool at the time of extubation.

Sarcopenia Impairs Prognosis of Patients with Hepatocellular Carcinoma: The Role of Liver Functional Reserve and Tumor-Related Factors in Loss of Skeletal Muscle Volume.

Sarcopenia impairs survival in patients with hepatocellular carcinoma (HCC). This study aimed to clarify the factors that contribute to decreased skeletal muscle volume in patients with HCC. The third lumbar vertebra skeletal muscle index (L3 SMI) in 351 consecutive patients with HCC was calculated to identify sarcopenia. Sarcopenia was defined as an L3 SMI value ≤ 29.0 cm2/m2 for women and ≤ 36.0 cm2/m2 for men. The factors affecting L3 SMI were analyzed by multiple linear regression analysis and tree-based models. Of the 351 HCC patients, 33 were diagnosed as having sarcopenia and showed poor prognosis compared with non-sarcopenia patients (p = 0.007). However, this significant difference disappeared after the adjustments for age, sex, Child–Pugh score, maximum tumor size, tumor number, and the degree of portal vein invasion by propensity score matching analysis. Multiple linear regression analysis showed that age (p = 0.015) and sex (p < 0.0001) were significantly correlated with a decrease in L3 SMI. Tree-based models revealed that sex (female) is the most significant factor that affects L3 SMI. In male patients, L3 SMI was decreased by aging, increased Child–Pugh score (≥56 years), and enlarged tumor size (<56 years). Maintaining liver functional reserve and early diagnosis and therapy for HCC are vital to prevent skeletal muscle depletion and improve the prognosis of patients with HCC.

Sarcopenia is a risk factor for the recurrence of hepatocellular carcinoma after curative treatment.

Sarcopenia, initially proposed as decreased of muscle mass and strength, is associated with aging and malignant diseases. The aim of the present study was to determine whether there is a correlation between sarcopenia and the recurrence of hepatocellular carcinoma (HCC) after curative treatment. We conducted a retrospective analysis of consecutive naive patients with HCC who underwent curative resection or radiofrequency ablation. To eliminate the influence of cause or the severity of liver damage, subjects were limited to those with HCC with hepatitis C-related cirrhosis and Child-Pugh class A liver function. Patients were assessed using computed tomographic measurement of muscle mass at the level of the third lumbar (L3) vertebrae, the L3 skeletal muscle index (L3 SMI). Sarcopenia was defined by using previously published, sex-specific cut-off value. Sarcopenia was present in 61 of 92 patients. Patients' median age was 71.5years (range, 47-84), and the baseline characteristics of patients were comparable between patients with and without sarcopenia except for sex, serum albumin level, prothrombin time, diabetes mellitus and body mass index. Recurrence rates at 1, 3 and 5years were 39.1%,77.1%,81.7% for patients with sarcopenia and 23.5%,59.5% and 75.7% for patients without sarcopenia, respectively (P = 0.03). Multivariate Cox analysis revealed that sarcopenia and preoperative α-fetoprotein of more than 40ng/mL were significant independent factors for recurrence. Sarcopenia is a risk factor for recurrence in patients with HCC who were treated with curative treatment.

Inclusion of Sarcopenia Within MELD (MELD-Sarcopenia) and the Prediction of Mortality in Patients With Cirrhosis

OBJECTIVES: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.

Skeletal muscle depletion predicts the prognosis of patients with hepatocellular carcinoma treated with sorafenib.

The aim of this study was to determine whether skeletal muscle depletion predicts the prognosis of patients with hepatocellular carcinoma (HCC) that is being treated with sorafenib. We evaluated 40 consecutive HCC patients who received sorafenib treatment. The skeletal muscle cross-sectional area was measured by computed tomography at the third lumbar vertebra (L3), from which the L3 skeletal muscle index (L3 SMI) was obtained. The factors contributing to overall survival, sorafenib dose reduction, and discontinuation of sorafenib were analyzed using the Cox proportional hazards model. L3 SMI (p = 0.020) and log (α-fetoprotein (AFP)) (p = 0.010) were identified as independent prognostic factors in HCC patients treated with sorafenib. The initial dose of sorafenib (p = 0.008) was an independent risk factor for sorafenib dose reduction, and log (AFP) (p = 0.008) was the only significant risk factor for the discontinuation of this drug. L3 SMI was not a risk factor for either dose reduction (p = 0.423) or the discontinuation (p = 0.132) of sorafenib. A multiple linear regression analysis determined the following relationship between skeletal muscle mass (assessed as L3 SMI) and the explanatory factors: L3 SMI = −0.1896 × (Age) − 10.3441 × (Child-Pugh score) − 9.3922 × (log (AFP)) + 1.6139 × (log (AFP)) × (Child-Pugh score) + 112.9166. Skeletal muscle depletion is inversely associated with age, Child-Pugh score, and log (AFP). Moreover, it is an independent prognostic factor for HCC patients treated with sorafenib.

Skeletal muscle depletion is an independent prognostic factor for hepatocellular carcinoma.

Skeletal muscle depletion or sarcopenia has been identified as a poor prognostic factor for various diseases. The aim of this study is to determine whether muscle depletion is a prognostic factor for hepatocellular carcinoma (HCC). We evaluated 217 consecutive patients with primary HCC. The skeletal muscle cross-sectional area was measured by computed tomography at the third lumbar vertebra (L3), from which the total body fat-free mass (FFM) and L3 skeletal muscle index (L3 SMI) were obtained. The factors contributing to overall survival (OS) were analyzed by univariate and multivariate Cox proportional hazards model. In univariate analysis, FFM (P = 0.0422), Child-Pugh classification (P = 0.0058), serum albumin level (P < 0.0001), serum AFP level (P < 0.0001), serum proteins induced by vitamin K absence or antagonist-II level (P < 0.0001), cancer stage (P < 0.0001), and curability of the initial treatment (P < 0.0001) were significantly associated with the prognosis of HCC. Multivariate analysis indicated that FFM (P = 0.0499), albumin level (P = 0.0398), and curability of the initial treatment (P = 0.0008) were independent prognostic factors. Sarcopenia was defined as an L3 SMI value of ≤29.0 cm(2)/m(2) for women and ≤36.0 cm(2)/m(2) for men, and 24 patients (11.1%) have sarcopenia. Sarcopenic patients showed a significantly lower OS than those without sarcopenia (P = 0.0043). Sarcopenic patients who were overweight (BMI >22) died earlier (P = 0.0129). Skeletal muscle depletion is an independent prognostic factor. Intervention to prevent muscle wasting might be an effective strategy for improving the outcome of HCC.

Frequency and Clinical Impact of Sarcopenia in Cirrhotic Patients with and without Hepatocellular Carcinoma

Purpose: Prognostic assessment of patients (pts) with cirrhosis remains a challenge, as the natural history is highly variable due to several factors, including hepatic synthetic function, and development of hepatocellular carcinoma (HCC) among others. Sarcopenia is defined as low levels of muscle mass, and this syndrome may be present in chronic and malignant diseases; however, it is not well studied and understood in pts with cirrhosis and pts with HCC. We aimed to establish the frequency of sarcopenia and if it predicts mortality in a cohort of cirrhotic pts with and without HCC. Methods: 163 pts with cirrhosis that were consecutively evaluated for liver transplant and had a computed tomography (CT) scan at the 3rd lumbar vertebrae were selected. Data were recovered from medical charts, skeletal muscle cross-sectional area was measured by CT in order to determine the L3 skeletal muscle index (L3 SMI) defined as total lumbar muscle cross sectional area adjusted for stature, and sarcopenia was defined using previously published gender-specific cutoffs. Results: 118 pts were males (72%), the mean age was 55±1 years, and 51 pts (31%) had HCC at the time of the CT. Median time of follow-up was 19±1 months. Etiology of liver cirrhosis was HCV (34%), alcohol (20%), autoimmune liver disease (13%), HBV (6%), and others (27%). Sarcopenia was present in 61 pts (37%), and there was no difference in the frequency of sarcopenia among pts with and without HCC (31% vs. 40%, P=0.3). By univariate Cox analysis the bilirubin (HR 1.01; P<0.001), INR (HR 6.42; P<0.001), creatinine (HR 1.01, P=0.001), albumin (HR 0.95, P=0.006), MELD (HR 1.12; P<0.001), Child-Pugh (HR 2.09; P<0.001), sodium (HR 0.89; P<0.001), L3 SMI (HR 0.98, P=0.05), and sarcopenia (HR 2.19; P=0.001) were associated with mortality. The presence of HCC was not associated with increased mortality (HR 1.12; P=0.6). By multivariate Cox regression analysis only the MELD score (HR 1.08, P=0.001), and sarcopenia (HR 2.18, P=0.001) were independently associated with early mortality. Median survival for sarcopenic pts was 19±5 months, compared to 30±2 months in non-sarcopenic pts (P=0.001). There was a poor correlation between sarcopenia and MELD score (r -0.13, P=0.1) and sarcopenia and Child-Pugh score (r 0.04, P=0.6). Conclusion: Sarcopenia is present in more than one third of pts with cirrhosis, and is not associated with the presence of HCC. Sarcopenia constitutes a strong and independent predictor of mortality in pts with cirrhosis and does not correlate with degree of liver dysfunction evaluated with conventional scoring systems. Further studies that include sarcopenia with conventional scores may allow significantly better prediction of mortality among cirrhotic pts with and without HCC.