Radiol Oncol 2023; 57(2): 168-177. doi: 10.2478/raon-2023-0025
168
research article
Radiological assessment of skeletal 
muscle index and myosteatosis and their 
impact postoperative outcomes after liver 
transplantation
Miha Petric
1,2
, Taja Jordan
3
, Popuri Karteek
4
, Sabina Licen
5
, Blaz Trotovsek
1,2
,  
Ales Tomazic
1,2
1 
Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
2 
Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
3 
Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
4 
Department of Computer Science, Memorial University of Newfoundland, St. John’s, NL, Canada
5 
Faculty of Health Sciences, University of Primorska, Izola, Slovenia
Radiol Oncol 2023; 57(2): 168-177.
Received 12 March 2023 
Accepted 16 May 2023
Correspondence to: Miha Petrič; Department of Abdominal Surgery, University Medical Centre Ljubljana, Zaloška cesta 7, SI-1000 Ljubljana, 
Slovenia. E mail: miha.petric@kclj.si
Disclosure: No potential conflicts of interest were disclosed.
This is an open access article distributed under the terms of the CC-BY license (https://creativecommons.org/licenses/by/4.0/).
Background. Liver transplantation offers curative treatment to patients with acute and chronic end-stage liver 
disease. The impact of nutritional status on postoperative outcomes after liver transplantation remains poorly under-
stood. The present study investigated the predictive value of radiologically assessed skeletal muscle index (SMI) and 
myosteatosis (MI) on postoperative outcomes.
Patients and methods. Data of 138 adult patients who underwent their first orthotopic liver transplantation were 
retrospectively analysed. SMI and MI in computer tomography (CT) scan at the third lumbar vertebra level were cal-
culated. Results were analyzed for the length of hospitalisation and postoperative outcomes.
Results. In 63% of male and 28.9% of female recipients, low SMI was found. High MI was found in 45(32.6%) patients. 
Male patients with high SMI had longer intensive care unit (ICU) stay (P < 0.025). Low SMI had no influence on ICU stay 
in female patients (P = 0.544), length of hospitalisation (male, P > 0.05; female, P = 0.843), postoperative complication 
rates (males, P = 0.883; females, P = 0.113), infection rate (males, P = 0.293, females, P = 0.285) and graft rejection 
(males, P = 0.875; females, P = 0.135). The presence of MI did not influence ICU stay (P = 0.161), hospitalization (P = 
0.771), postoperative complication rates (P = 0.467), infection rate (P = 0.173) or graft rejection rate (P = 0.173).
Conclusions. In our study, changes in body composition of liver transplant recipients observed with SMI and MI had 
no impact on postoperative course after liver transplantation. CT body composition analysis of recipients and uni-
formly accepted cut-off points are crucial to producing reliable data in the future.
Key words: muscle mass; liver transplantation; myosteatosis; skeletal muscle index; GLIM score
Introduction
Since 1963 when the first liver transplantation (LT) 
was performed by Starzl
1
, it has become a standard 
treatment modality for patients with acute liver 
failure and chronic liver disease.
2
 Ninety percent 
5-year survival rate and better quality of life are 
the two most important outcomes of LT.
2
 Most liv-
er transplant centres use the Model for End-stage 
Liver Disease (MELD) score for organ allocation.
3
 
Patients with MELD score 15 or more, patients with 
poor quality of life due to chronic liver disease 

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 169
symptoms (diuretic-intractable ascites, variceal 
bleeding, pruritus, cachexia), and patients with 
acute liver failure are those who benefit most from 
LT.
3
 MELD score can underestimate the severity of 
liver disease in specific groups of patients (acute 
on chronic liver disease, presence of sarcopenia, 
chronic kidney disease, etc.).
3
 Several modifica-
tions of the MELD score have been introduced, but 
none offers a more reliable and accurate scoring 
system. Albumin-bilirubin (ALBI) score is mainly 
used as an objective method to assess liver func-
tion and predict postoperative complications, par-
ticularly after hepatectomy in patients with hepa-
tocellular carcinoma (HCC).
4
 Its role in determin-
ing post-LT outcomes is not yet determined. Two 
main objective parameters of nutritional status are 
sarcopenia and myosteatosis (MI). The European 
Working Group on Sarcopenia defines sarcopenia 
as the presence of low muscle mass (under the 5
th
 
percentile) and low muscle function (strength or 
performance) in patients with advanced age, can-
cer, or other diseases.
5,6
 Myosteatosis is defined 
as the abnormal fatty transformation of skeletal 
muscle. It negatively affects muscle strength and is 
common in advanced age
7,8
, diabetes
7,8
, obesity
9,10
, 
chronic
9
, and malignant diseases.
11,12
 Overview 
of the literature shows large number of different 
methods used for body composition assessment in 
patients with liver cirrhosis.
13
 There is still no con-
sensus on the best tools for each body component 
in patients with liver cirrhosis. Most frequently 
used are computed tomography (CT), bioimped-
ance analysis (BIA), dual-energy X-ray absorp-
tiometry (DXA) and anthropometry.
13
 Some of 
them BIA, DXA and body mass index (BMI)) are 
not applicable in patients with end-stage liver dis-
ease due to frequent water retention.
14,15
 In the last 
decade, computed tomography with automated or 
semiautomated body composition analysis at the 
third lumbar vertebra has emerged as an objec-
tive method of defining the nutritional status of 
patients with chronic liver disease.
15,16
 Nutritional 
assessment with CT is not affected by water reten-
tion or presence of ascites. Skeletal muscle volume 
and myosteatosis can be measured from CT images 
obtained as a part of routine pre-transplant evalu-
ation.
14
 Skeletal muscle mass index (SMI) is calcu-
lated as muscle mass area divided by the square 
of the height. The Global Leadership Initiative on 
Malnutrition (GLIM)
16
 score was introduced as 
a potential nutritional assessment tool in recent 
years. It was shown to have good predictive value 
as a risk assessment tool for postoperative morbid-
ity and mortality in patients after colorectal sur-
gery.
17
 However, its role as a predictive factor in LT 
is not yet established.
This study aimed to investigate feasibility of 
radiological assessment of a nutritional status of 
a patient and the predictive value of SMI and MI 
on postoperative complications, length of hospi-
talization, liver graft rejection, and mortality. We 
further compared the predictive value of SMI and 
MI with MELD, ALBI, and GLIM scores.
Patients and methods
We retrospectively analyzed 138 adult patients who 
had first orthotropic LT from brain dead donors be-
tween 1.1.2012 and 1.1.2020 in our institution. We 
excluded patients who had re-LT procedure and 
those whose abdominal CT scan could not be ob-
tained from data base or received reduced size and 
liver graft from donation after cardiac death (DCD) 
donor. From the medical database, we collected re-
cipient age, gender, body mass index, underlying 
liver disease, presence of ascites, hepatocellular 
carcinoma (HCC), and laboratory parameters (se-
rum levels of sodium, creatinine, albumin, pro-
tein, bilirubin, and International normalized ratio 
(INR)). We calculated MELD and ALBI scores from 
laboratory parameters. Among GLIM criteria, we 
used chronic liver failure and end-stage liver dis-
ease as etiologic and SMI or MI as phenotypic cri-
teria. Length of intensive care unit (ICU) stay, hos-
pitalization, postoperative complications accord-
ing to Clavien-Dindo classification
18
, infections, 
and 90-day mortality were collected from the da-
tabase of liver recipients and analyzed. Diagnosis 
of liver rejections was confirmed with laboratory 
tests and histological examination of all liver graft 
specimens obtained by ultrasound-guided biopsy. 
Acute rejection was defined with 6 points or more 
according to the liver allograft fibrosis score.
19
The Slovenian National Medical Ethics 
Committee approved our study design (approval 
number 0120–230/2018–10) and waived the need to 
obtain informed consent from participants.
CT-body composition analysis 
Abdominal CT scans were obtained from the hos-
pital database system. In case of multiple CT scans, 
we used last CT scan before LT procedure. A single 
slice of each patient at the level of the 3
rd
 lumbar 
vertebrae was selected for automatic segmentation. 
CT scans were analysed using the “Automated 
Body Composition Analyzer using Computed to-

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 170
mography image Segmentation” (ABACS)
20
 soft-
ware, which uses predefined Hounsfield units 
(HU) values to recognize different tissues. ABACS 
uses HU values from −29 to +150 HU to assess and 
calculate the total cross-sectional area for mus-
cular tissue (SMA – skeletal muscle area). The L3 
skeletal muscles included the psoas muscle, the 
lumbar muscles, the erector spinae, the transver-
sus abdominis muscle, the internal and external 
oblique muscles, and the rectus abdominis. SMI 
was calculated using the following formula: SMI 
= SMA (cm
2
) / height2 (m
2
)
9,21
 and patients were di-
vided into a group with lower SMI (men < 52.4 cm
2
/
m
2
, women < 38 cm
2
/m
2
)
9,21 
and another with nor-
mal SMI. MI was determined by the medium value 
of HU in a skeletal muscle area. We used recently 
defined threshold parameters for MI in a patient 
with a chronic liver disease (< 33 HU in patients 
with a BMI ≥ 25 kg/m
2
 and < 41 HU in those with a 
BMI < 25).
22-24
 Based on previous literature findings 
and conclusions no adjustment for sex was made 
for MI.
23,24
Statistical analysis 
Data were analysed using SPSS for macOS, 26
th
 edi-
tion. Descriptive statistics such as frequencies, per-
centages, mean/median, and standard deviations 
were used for description and summary. Because 
the data were not normally distributed, patient 
characteristics were compared between groups us-
ing the Kruskal-Wallis test and the Mann-Whitney 
U test. In addition, Spearman rank-order correla-
tion and multiple linear regression were used to 
determine the relationship between variables and 
predict patient outcomes based on their character-
istics and condition, as well as the chi-square in-
dependence test. A P-value ≤ 0.05 was considered 
statistically significant.
Results 
Patients characteristics 
Between 1.1.2012 and 1.1.2020, 138 patients (100 
men and 38 women) met the criteria for inclusion 
in the study. The median age was 57.5 years (22 to 
69 years). Table 1 provides general data on the pop-
ulation laboratory and clinical variables.
Sixty-one (61, 44.2%) patients had LT due to in-
herited or metabolic liver disease, 60 patients had 
alcoholic liver disease (43.5%), and 17 patients had 
virus-related liver disease (12.3%). At the time of 
LT, 80 (58%) patients had ascites, and 27 patients 
had HCC (19.4%).
Incidence of low SMI and MI 
In our study group, 63% of male and 28.9% of fe-
male patients had low SMI. MI was present in 45 
(32.6%) patients. We found no statistical signifi-
cance between the aetiology of underlying liver 
disease and SMI (P = 0.214). The aetiology of liver 
disease had a statistically significant influence on 
the incidence of MI. Patients with alcoholic ae-
tiology had more fatty infiltrated muscles than 
patients with other liver disease aetiologies (P = 
0.008) (Table 2). 
A Spearman’s rank-order correlation was run 
to determine the relationship between the MI and 
BMI. There was a moderate, negative correlation 
between MI and BMI, which was statistically sig-
nificant (rs = -0.597, p < 0.000). 
TABLE 1. Laboratory and clinical data of patients 
Variable Min Max IQR SD
95% CI
Lower Upper
BMI 15 38 6 4.775 25.13 26.74
Waiting 
time for liver 
transplantation 
(days)
1 691 166 151.311 108.44 159.38
Sodium 121 147 6 4.701 136.09 137.6 8
Creatinine 41 696 46 67.0 82 85.91 108.49
Albumin 10 62 10 7.674 31.28 33.86
Protein 23 89 12 11.494 65.80 69.74
Bilirubin 2 687 56 107.535 51.83 88.04
INR 1 4 1 .502 1.44 1.61
MELD score 7 46 9 6.700 14.30 16.56
ALBI score -4 0 1.13 0.802 -1.87 -1.60
ALBI score = albumin-bilirubin score; BMI = body mass index; INR = international normalized 
ratio; IQR = Interquartile range; MELD score = model for end-stage liver disease score
TABLE 2. Aetiology of liver disease and incidence of myosteatosis
Variable
Myosteatosis
no yes
Liver failure
Alcohol-related 32 28
Virus-related 14 3
Other 47 14
χ2 9.717
Degrees of freedom (Df) 2
p 0.008

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 171
Eighty patients (57 .9%) had decompensated liver 
cirrhosis with the presence of ascites at the time of 
CT scan. The Mann-Whitney U test indicates that 
ascites significantly impacted patients’ SMI. The 
presence of ascites correlated with low SMI (P < 
0.05, Figure 1) and had no impact on the incidence 
of MI (P = 0.244).
Presence of HCC in patients with liver disease 
(27 patients, 19.6%) had no influence on SMI (P = 
0.546) or MI (P = 0.174).
Influence of low SMI on hospitalization
The Mann-Whitney U test indicates that male pa-
tients with normal or high SMI (> 52.4 cm
2
/m
2)
 had 
a longer ICU length of stay (P < 0.025). Linear re-
gression was calculated to predict ICU length of 
stay based on SMI. A significant regression equa-
tion was found (F (1.96) = 6.823, P = 0.010) (Figure 2), 
with R
2
 of 0.066. SMI was found to significantly 
predict length of ICU stay (β = 0.258; 95% CI 0.026, 
0.189; P = 0.010). The predicted length of stay equals 
-1.117+0.107 (SMI) days when SMI is measured in 
cm
2
/m
2
. The ICU length of stay increased by 0.107 
days for each cm
2
/m
2
 of SMI in the male population. 
A Spearman’s rank-order correlation showed no 
difference in hospitalization time between males 
with low or normal SMI. Mann-Whitney U test in-
dicates statistically significant differences between 
low or normal SMI (P < 0.05) in more extended hos-
pitalization in male patients with normal SMI. In 
addition, the linear regression analysis was per-
formed to predict the length of hospital stay based 
on SMI in male patients; however, no statistically 
significant regression equation was found (β = 
-0.031; 95% CI -0.656, 0.480; P > 0.05). In the female 
population, we found no statistically significant 
influence of SMI on ICU length of stay (β = -0.123; 
95% CI -0.741, 0.463; P = 0.544) and hospitalization 
time (β = 0.013; 95% CI 0.075, 0.941; P = 0.843).
Influence of MI on hospitalisation
The Mann-Whitney U test indicates that there 
were no differences among the groups (MI and no-
MI) regarding the ICU length of stay (P = 0.161) or 
hospitalization (P = 0.771).
Influence of SMI and MI on postoperative 
complications
Postoperative complications of stage 2 or more by 
Clavien-Dindo classification
19
 were present in 79 
patients (57.2%). Infection occurred in 59 patients 
(42.8%), most commonly as intra-abdominal in-
fection (50.8%), respiratory tract infection (23.7%) 
and urosepsis (6.8%). 5 (3.6%) patients developed 
critical illness myopathy. Surgical intervention 
was needed in 38% of patients with postoperative 
complications.
There was no statistically significant differ-
ence in the frequency of postoperative compli-
cations between males (P = 0.883) and females  
(P = 0.113) with low or normal SMI. The postopera-
tive infection rate was similar in males (P = 0.293) 
and females (P = 0.285) with low or normal SMI. 
MI did not show significant influence on postop-
erative complications (P = 0.839) and infection rate  
(P = 0.703).
FIGURE 1. Correlation between ascites and skeletal muscle index.
FIGURE 2. Scatter diagram showing a positive correlation between the intensive 
care unit length of stay (days) and skeletal muscle index.

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 172
Influence of SMI and MI on liver graft 
rejection
Rejection was diagnosed in 22 patients (16.1%), 20 
in male and 2 in female patients. We found no sta-
tistically significant influence of SMI (males, P = 
0.875; females, P = 0.135) and MI (P = 0.449) on liver 
graft rejection.
Influence of MELD and ALBI score on 
postoperative outcomes
The median MELD score was 14 (7 – 46). A 
Spearman’s rank-order correlation was run to de-
termine the relationship between the MELD score 
and ICU length of stay (days). There was a weak, 
positive correlation between the MELD score and 
ICU length of stay, which was statistically signifi-
cant (r
s
 = 0.261, P < 0.002). There was no significant 
relationship between the MELD score and compli-
cation rate or length of hospitalization (P > 0.05). 
There is a week, positive correlation between 
the ALBI score and ICU length of stay and hospi-
talisation time, which was statistically significant 
(r
s
 = 0.279, P < 0.001; r
s
 = 0.197; P = 0.022). There is no 
correlation between the ALBI score and postopera-
tive complications.
GLIM score
GLIM score using skeletal muscle index as a 
phenotypic factor
We analyzed differences between patients who 
meets criteria for positive GLIM score (acute or 
chronic liver disease as etiological factor and skel-
etal muscle index as a phenotypic factor) and those 
with negative GLIM score regarding ICU length 
of stay, postoperative complications, rate of infec-
tions, graft rejections and mortality.
Based on the chi-square independence test, no 
association was found between the groups in post-
operative complications (χ2(1) = 0.600; P = 0.438), 
rate of infections (χ2(1) = 0.918; P = 0.338), graft re-
jection (χ2(1) = 1.205; P = 0.272), and mortality (χ2(1) 
= 0.232; P = 0.630). In addition, there were no statis-
tically significant differences in ICU length of stay 
between groups (χ2(14) = 15.125; P = 0.370), based 
on the Mann-Whitney test.
GLIM score using myosteatosis as a phenotypic 
factor
We analyzed differences between patient who 
meets criteria for positive GLIM score (acute or 
chronic liver disease as etiological factor and my-
osteatosis as a phenotypic factor) and those with 
negative GLIM score regarding ICU length of stay, 
postoperative complications, rate of infections, 
graft rejections and mortality.
Based on the chi-square independence test, 
there was no association between the groups in 
terms of postoperative complications (χ2(1) = 1.378; 
P = 0.242), infection rate (χ2(1) = 2.921; P = 0.089), 
graft rejection (χ2(1) = 0.873; P = 0.352), and mor-
tality (χ2(1) = 0.010; P = 0.922). In addition, there 
were no statistically significant differences in ICU 
length of stay between groups (χ2(14) = 16.271; P = 
0.297), based on the Mann-Whitney test.
Multiple linear regression analysis
Multiple linear regression was calculated to pre-
dict ICU length of stay on SMI and infection. A sig-
nificant regression equation was found (F (2. 95) = 
11.192, P < 0.000), with R
2
 of 0.191. SMI was found to 
significantly predict length of ICU stay (β = 0.292; 
95% CI 0.045, 0.199; P = 0.002). The length of ICU 
stays increased by 0.122 days per cm
2
/m
2
 SMI in 
male patients with infection.
Mortality
In our study group, 5 (3.6%) patients died in the 
first 90 days after liver transplantation. Two pa-
tients died immediately after the procedure due 
to irreversible haemorrhagic shock with dissemi-
nated intravascular thrombosis and abdominal 
organ ischemia. The cause of death in three pa-
tients was sepsis with multiorgan failure in one 
patient (day 66), and severe postoperative bleed-
ing, intraabdominal infection with liver abscess, 
and multiorgan failure in two patients (34 and 53 
days). One year survival rate was 95%. Due to the 
small number of patients, statistical analysis was 
not performed.  
Discussion
Malnutrition with skeletal muscle mass loss is a 
frequent complication in patients with chronic or 
end-stage liver disease.
25
 The aetiology of malnu-
trition is multifactorial.
23
 Insufficient calorie intake 
(early satiety, loss of appetite, alcohol consump-
tion, diet restriction), metabolic abnormalities, cat-
abolic state of metabolism, and malabsorption are 
the main contributors to muscle loss.
25,26
 It affects 
from 30 to 70%
27,28
 of patients with end-stage liver 
disease and up to 80%
27
 of patients with alcohol-re-

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 173
lated liver disease. Myosteatosis affects more than 
half of patients with chronic liver disease.
9
 In our 
patient population, we used selected parameters 
for low SMI (men < 52.4 cm
2
/m
2
, women < 38 cm
2
/
m
2
)
9,21
 and MI (< 33 HU in patients with a BMI ≥ 25 
kg/m
2
 and < 41 HU in those with a BMI < 25).
22-24
 
These cut-off values were determined specifically 
for patients on LT waiting list are the most widely 
used in literature.
22-24
 Low SMI was present in 63% 
of males and 28.9% of females. More than one-
third of the patients (32.6%) had fatty infiltration 
of the skeletal muscle. Patients with alcoholic aeti-
ology had more fat-infiltrated muscles than other 
aetiologies for end-stage liver disease (P < 0.008). 
Alterations in the metabolism of fatty acids, eating 
habits, and alcohol consumption probably result in 
fatty infiltration of skeletal muscle fibres. However, 
due to the small numbers of patients (3 patients) 
with non-alcoholic steatohepatitis (NASH) or non-
alcoholic fatty liver disease (NAFLD) in our study 
group, we cannot properly assess the relationship 
between the aetiology of underlying liver disease 
and the degree of MI.  
Several studies have shown that sarcopenia 
and myosteatosis are associated with a higher in-
cidence of postoperative complications, infection 
rate, duration of hospitalization, and mortality in 
a wide range of gastrointestinal cancers, including 
tumours of the hepatopancreatobiliary system.
29-32
 
Lack of a strictly defined patient population, dif-
ferent methods of measurement of muscle mass 
and function, and the absence of uniformly ac-
cepted cut-off points for patients with chronic or 
end-stage liver disease are the leading causes for 
wide ranges of sarcopenia incidence reported in 
the literature.
14,21,33
 Therefore, the selected cut-off 
points for patients with cancer are used for evalua-
tion, which may affect the quality of results. 
Sarcopenia is associated with poorer outcomes 
in patients with chronic liver disease on the wait-
list or after LT.
34,35
 Patients with end-stage liver 
disease and sarcopenia have shorter survival than 
non-sarcopenic patients (22 ± 3 vs. 95 ± 22-month, P 
< 0.001).
9,36
 The main cause of death in patients with 
end-stage liver disease is sepsis.
37
 Incidence of sep-
sis as a cause of death is even higher in presence 
of sarcopenia (36% vs. 16%, P < 0.001) or myosteato-
sis (32% vs. 19%, P = 0.020).
9
 Lower muscle mass is 
also associated with a higher incidence of hepatic 
encephalopathy in patients with end-stage liver 
disease.
38,39
 On the other hand, a group from USA
40
 
showed that sarcopenic patients had a higher ten-
dency for pulmonary complications than the non-
sarcopenic group (38% vs. 18%, P = 0.100); however, 
there was no significant difference in morbidity 
and mortality. 
CT imaging is considered as the gold standard 
for body composition assessment. SMI calculated 
on the level of third lumbar vertebra is superior 
since it correlates best with the actual quantity of 
the muscles in the body.
41
 It is not affected by as-
cites and is part of preoperative evaluation in pa-
tients with hepatocellular carcinoma or the com-
plications of portal hypertension. The value of SMI 
as a predicting factor for postoperative morbidity 
and mortality is yet to be determined. However, 
it has been shown in several reports that it has a 
negative impact on postoperative outcomes. Lower 
values of SMI are associated with more significant 
postoperative mortality, higher infection risk, and 
postoperative complications, more extended in-
tensive care unit stay, ventilator dependency, and 
higher waitlist mortality rates in patients with end-
stage liver disease.
33,42,43
 SMI as a predicting factor 
for higher mortality rate in patients with end-stage 
liver disease was superior to other nutritional as-
sessment indicators, such as BMI, upper arm mus-
cle circumference, and triceps skinfold thickness.
44
 
However, some other reports showed contrasting 
findings. Using SMI for prespecified definitions of 
sarcopenia had no impact on mortality or delisting 
from the transplant waitlist between patients with 
and without sarcopenia.
45
 Length of hospitaliza-
tion following LT, days of hospitalization during 
the first year post-LT, survival at one year, or over-
all survival was not different between sarcopenic 
and nonsarcopenic patients.
46
 Low SMI alone was 
not associated with graft and patient survival (P 
= 0.273 and P = 0.278) after LT.
47
 These conflicting 
results are probably due to heterogeneity of used 
specific cut-off points (sex, age, race) and lack of 
strictly defined parameters representative unique-
ly for patients with chronic liver disease. We found 
a negative correlation between BMI and SMI, 
probably due to high-volume ascites in the patient 
population This confirms findings that BMI is not 
suitable for body assessment in patients with end-
stage liver disease. In our study, the presence of as-
cites was associated with significantly lower SMI 
(P < 0.05) in patients with end-stage liver disease 
but did not influence MI. There is a weak, positive 
correlation between SMI and ICU length of stay in 
male patients, which was statistically significant 
(rs = 0.226, P < 0.025). We speculate that the main 
reason is a more pronounced systemic inflamma-
tory reaction to surgical stress in patients with 
preserved muscle mass. It is known that muscle 
mass is mandatory for the normal function of the 

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 174
immune system.
48
 Experience from Japan
49
 shows 
a connection between low SMI and decreased 
incidence of graft rejection in living-donor liver 
transplantation. Analysis of our results shows no 
statistically significant difference in postopera-
tive complications, rate of postoperative infection, 
and liver graft rejection rate between males and 
females with low or normal SMI (P > 0.05). BIA is 
commonly used technique in body composition 
analysis in every day clinical practice.
50
 Its key pa-
rameters are resistance, reactance and phase angle 
(PA). PA is found to be associated with outcomes 
in different diseases and has been found to be use-
ful for monitoring fluid changes and response to 
interventions.
50
 The main limitation is the com-
plexity of the determinants that requires its ad-
justment to the individual phenotypic diagnosis 
of each patient. Results can be affected by altered 
water and electrolyte balance, fluid retention and 
diuretic therapy.
50
 DXA allows for the quantifica-
tion of three body compartments (bone mass, fat 
mass, and bone fat-free mass (or lean mass)) based 
upon the differential tissue attenuation of X-ray 
photons.
51
 However, it can be affected by presence 
of ascites.
52
 Even though DXA can be modified to 
exclude influence of ascites or tissue oedema the 
correlation between the lean mass index and SMI 
was weaker (γ = 0.29, p = 0.035) and falsely high in 
patients with ascites before liver transplantation.
53
 
Main disadvantages of DXA compared to CT is in-
ability to assess muscle mass quality (myosteato-
sis).
51
Myosteatosis is a more clearly defined factor, 
and its influence is more uniformly established in 
literature.
54
 However, there are many different cut 
off points (HU < 25 to HU < 39) reported in litera-
ture in patients with malignant disease.
55
 Majority 
of reports uses a Martin cut-off point (< 33 HU in 
patients with a BMI ≥ 25 kg/m
2
 and < 41 HU in 
those with a BMI < 25)
56
 for determining presence 
of myosteatosis. Martin cut-off point is also recent-
ly defined threshold parameters for MI in a patient 
with a chronic liver disease.
22-24
 It has been shown 
that severely ill patients with myosteatosis have a 
lower survival rate than those without fatty infil-
tration in muscles.
57
 Myosteatosis negatively im-
pacts the survival of patients with end-stage liver 
disease (28 ± 5 vs. 95 ± 22-month, P < 0.001)
9,36
 and is 
associated with longer hospitalization and higher 
morbidity.
43
 Patients with myosteatosis showed a 
higher mortality rate, most commonly due to res-
piratory and septic complication.
47
 Myosteatosis 
had no influence on ICU length of stay (P = 0.161), 
hospitalisation (P = 0.771), postoperative complica-
tions (P = 0.839), infection rate (P = 0.703) and graft 
rejection (P= 0.449) in our patient population.
The nutritional status on the waitlist for LT as a 
possible risk factor is overlooked with the MELD 
score.
58
 Another important limiting factor of the 
MELD score is using serum creatinine levels for 
score calculation.
3
 Serum creatinine level may 
vary significantly and is influenced by chronic 
kidney disease, ascites, paracentesis, and the in-
fluence of gender and liver disease on skeletal 
muscle mass.
59
 Variation of serum creatinine levels 
may affect the MELD score and underestimate the 
severity of liver disease.
58
 Thus, several modifica-
tions of the MELD score were developed to incor-
porate the nutritional parameters. Body composi-
tion MELD (BC-MELD)
60
 has a better predictive 
value for waiting list mortality than MELD score. 
MELD-sarcopenia score showed a positive predic-
tive value in patients with a lower score (< 15) on 
the postoperative course; however, it was not use-
ful in patients with MELD above 15.
61,62
 Combining 
SMI in MELD in multivariate analysis (AUROC= 
0.812) is significantly better than MELD alone 
(AUROC = 0.787) for predicting 5-year mortality 
(P < 0.001).
44
 We found a weak, positive correlation 
between the MELD score and ICU length of stay 
(rs = 0.261, P < 0.002). ALBI score showed promis-
ing results in more accurate prediction of liver dis-
ease severity and mortality on waitlist compared 
to the Child-Pugh score; however, its predictive 
value was inferior to the MELD score.
63
 Patients 
with pre-transplant ALBI grade 3 liver disease had 
increased mortality after LT.
64
 We found a weak, 
positive correlation between the ALBI score and 
ICU length of stay and hospitalization time, which 
was statistically significant (rs = 0.279, P < 0.001; rs 
= 0.197; P = 0.022). We found no correlation between 
the ALBI score and postoperative complications. 
The GLIM score
16
 was established as a potential 
assessment tool for evaluating patient nutritional 
status in recent years. Our results showed no dif-
ference between the patients who met GLIM cri-
teria and those who did not, regarding ICU stay, 
length of hospitalization, postoperative complica-
tions, infection, and mortality.
We believe that nutritional status in a patient 
with end-stage liver disease is an essential aspect 
of pre-transplant workup. However, its precise 
role is not yet determined. LT is a complex surgi-
cal procedure influenced by numerous factors. In 
the early phase of LT, donor characteristics and 
comorbidities, quality of liver graft retrieval, liver 
graft quality, cold preservation duration, ischemic 
damage to the liver graft during static cold storage, 

Radiol Oncol 2023; 57(2): 168-177.
Petric M et al. / Radiological assessment of skeletal muscle index and myosteatosis 175
recipient medical conditions and comorbidities, 
surgical procedure, and early postoperative ther-
apy are by our opinion the most essential factors. 
However, muscle mass status, muscle function 
and myosteatosis are crucial factors in a period of 
rehabilitation.
65
Patient with cachexia or with high-risk (< 18.5 kg/
m
2
, Child-Pough C)
66
 to lose muscle mass should 
be screened and involved in intensive but person-
alized nutritional support therapy. Nutritional re-
quirements in end stage liver disease are 35 kcal/
kg per day in non-obese patients (BMI 30 kg/m
2
) 
and 1,2g/kg per day intake of proteins.
66
 It is safe 
to calculate requirements based on the dry weight 
of a patients.
66
 In presence of hepatic encephalopa-
thy (HE), animal protein should be substituted 
with vegetable protein origin. Randomized control 
study
67
 showed that substitution of animal protein 
with vegetable protein for a period of six months 
(30–35 kcal/kg/d,1.0–1.5 g/kg/d protein) improved 
neuropsychiatric performance in patients with 
minimal HE and decrease their risk of develop-
ing overt HE compared to no intervention. It is 
unreal to expect to gain muscle mass in cirrhotic 
patients, but muscle mass preservation should be 
focus of such nutritional interventions. There are 
several strategies to prevent muscle mass loss in 
patients with end stage liver disease. First strategy 
is nutritional supplementations. Patients should 
have frequent small meals to avoid prolong fast-
ing period (> 6 h).
66,68,69
 Enteral supplements with 
side branched amino acids should be adminis-
tered.
66,68,69
 Snacks rich in carbohydrates should 
be taken as a late-night snack.
66,68,69 
Second, physi-
cal activity in a form of resistance and endurance 
exercise, is probably appropriate and beneficial.
70
 
Micronutrition, especially administration of fat-
soluble vitamins
71
 and ammonia lowering thera-
py
72
 is also important. Role of immunonutrition in 
patient with end stage liver disease is not yet estab-
lished.
66,73
 Post-transplant screening is advised in 
all patients after liver transplantation.
66,73
 
There are several drawbacks to our study. The 
two most important are the retrospective nature 
of data collection and the lack of functional assess-
ment of recipients’ muscles. Another factor that 
may influence results is the relatively small num-
ber of cases that may affect some results or may 
not produce statistical significance due to the com-
plexity of the treatment and numerous factors that 
determine its outcome.
In conclusion radiological assessment of a pa-
tient’s nutritional status at the third lumbar ver-
tebra represents an objective and reproducible 
method. It should become a standard screening 
tool in patients with acute or chronic end-stage 
liver disease. Due to complexity of liver transplant 
procedure, liver graft and liver recipients’ factors, 
it is difficult to established impact of a skeletal 
muscle index and myosteatosis on postoperative 
outcomes. However, nutritional interventions 
and physical activity should be part of the clinical 
pathway in patients with end-stage liver disease 
waiting for liver transplantation. Prospective ran-
domized controlled studies are not possible due 
to ethical considerations; hence, standardization 
and uniformity in definitions, methods, and cut-
off points are crucial to producing reliable data in 
the future.
Acknowledgments 
Authors would like to acknowledge all partici-
pants in liver transplant programme in our insti-
tution for their dedicated work.
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