Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation

We thank Drs. Clark and Cross for their interest in our study1 and will respond to their comments. We agree that one limitation of our study is that only patients who went on to receive liver transplantation were included, and patients who could have had sarcopenia might not have been listed. However, none of our patients evaluated for liver transplantation have been rejected solely on the basis of sarcopenia. The current evidence suggests that only “extreme sarcopenia,” previously defined differently as the lowest tertile of the total psoas area (TPA),2 the lowest quartile of the TPA,3 or the lowest sextile of the third lumbar skeletal muscle index,1 should be considered a contraindication for liver transplantation. On the other hand, in our cohort of patients, all underwent a nutritional evaluation as part of the liver transplant assessment with advice about increasing protein intake and leucine supplementation, but none of them had nasogastric or nasoenteral feeding. We normally used nasogastric or nasoenteral feeding only for those patients with a body mass index less than 18.5 kg/m2 because this has been shown to be a risk factor for mortality after liver transplantation,4 but none of the patients in this cohort had a body mass index below this threshold. Finally, because current methods used to assess liver disease severity, such as the Model for End-Stage Liver Disease (MELD) score, do not give a functional assessment of the patient's fitness, we believe that the next step is to evaluate the development of composite scores, including new scores such as MELD-sarcopenia and MELD-psoas,5, 6 or to assign exemption points to those patients with sarcopenia so that they can undergo transplantation before they develop extreme sarcopenia. Nevertheless, this issue should be evaluated preferentially in prospective and multicenter controlled clinical trials.7 Aldo J. Montano-Loza, M.D., M.Sc., Ph.D. Division of Gastroenterology and Liver Unit University of Alberta Hospital Edmonton, Alberta, Canada