Sex is a major effect modifier between body composition and mortality in patients with cirrhosis assessed for liver transplantation

Background and Aims: Body composition predicts mortality in patients with cirrhosis. The impact of sex on this association is unknown. We investigated the impact of sex on this association in patients with cirrhosis assessed for liver transplantation. Methods: This single-centre retrospective cohort study included adults assessed for liver transplantation. Nutritional status was assessed using the Royal Free Hospital-Global Assessment (RFH-GA). Body composition at the third lumbar vertebrae was determined. SarcopeniaSMI was defined as Skeletal Muscle Index <50 cm2/m2 in males and <39 cm2/m2 in females. SarcopeniaPMI was defined as the sex-specific 25th percentile of the Psoas Muscle Index. Patients were assessed for the occurrence of liver transplantation and death. Analyses were stratified by sex. Results: The cohort comprised 628 patients, including 199 females and 429 males. Both groups were similar in terms of baseline liver disease severity by Model for End-stage Liver Disease (MELD) (p =.98) and nutritional status (p =.24). SarcopeniaSMI was present in 41% of males compared to 27% of females (p <.001). In the male cohort, when adjusted for age and MELD, sarcopeniaPMI (aHR 1.74, 95% CI 1.08–2.80) and RFH-GA (aHR 1.40, 95% CI 1.03–1.90) remained independent predictors of mortality. Adipose tissue had no impact on outcomes in males. In female patients, adipose tissue (TATI or VATI depending on the multivariable model) was independently associated with mortality, whereas sarcopenia and malnutrition were not. Conclusions: This study demonstrates that male patients were susceptible to low muscle mass, whereas female patients were not. Future research in this patient population should minimize sex-related bias and present data for both groups separately