Silva TF, Loschi TM, Boteon APCS, Boteon YL. Imaging-based assessment of sarcopenia in liver transplant candidates: A systematic review. World J Gastroenterol 2025; 31(43): 112076 [DOI: 10.3748/wjg.v31.i43.112076]
Corresponding Author of This Article
Yuri L Boteon, MD, PhD, FACS, Professor, Transplant Centre, Hospital Israelita Albert Einstein, 627/701 Albert Einstein Avenue, Sao Paulo 05652-900, Brazil. yuri.boteon@einstein.br
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastroenterol. Nov 21, 2025; 31(43): 112076 Published online Nov 21, 2025. doi: 10.3748/wjg.v31.i43.112076
Imaging-based assessment of sarcopenia in liver transplant candidates: A systematic review
Thaynara Flosi Silva, Thais Mellato Loschi, Amanda P C S Boteon, Yuri L Boteon
Thaynara Flosi Silva, Thais Mellato Loschi, Amanda P C S Boteon, Yuri L Boteon, Transplant Centre, Hospital Israelita Albert Einstein, Sao Paulo 05652-900, Brazil
Thaynara Flosi Silva, Yuri L Boteon, Faculdade Israelita de Ciências da Saúde Albert Einstein, Instituto Israelita de Ensino e Pesquisa Albert Einstein, Sao Paulo 05652-900, Brazil
Author contributions: Boteon YL, Boteon APCS, and Silva TF conceived the idea and designed the study; Silva TF and Loschi TM performed the literature search and analyzed the data; Silva TF and Boteon YL drafted the manuscript; Boteon APCS and Boteon YL performed the critical revision of the manuscript for intellectual content, and supervision of the study process. All authors reviewed the draft, contributed to editing and approved the final manuscript version.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yuri L Boteon, MD, PhD, FACS, Professor, Transplant Centre, Hospital Israelita Albert Einstein, 627/701 Albert Einstein Avenue, Sao Paulo 05652-900, Brazil. yuri.boteon@einstein.br
Received: July 17, 2025 Revised: September 23, 2025 Accepted: October 23, 2025 Published online: November 21, 2025 Processing time: 126 Days and 20.6 Hours
Abstract
BACKGROUND
Sarcopenia is prevalent among patients with end-stage liver disease (ESLD) and is associated with adverse outcomes both before and after liver transplantation (LT). Accurate assessment of muscle mass is essential for effective risk stratification and optimization of transplant outcomes.
AIM
To identify imaging modalities used to assess sarcopenia in ESLD patients awaiting LT, and evaluate the clinical utility of each technique in predicting waitlist mortality, length of hospital stay, and post-transplant survival.
METHODS
A systematic search was conducted in PubMed, MEDLINE, EMBASE, and Scopus for studies published between May 2015 and May 2025. Eligible studies included original research evaluating sarcopenia using imaging techniques in ESLD patients listed for LT. Due to heterogeneity in study design, diagnostic criteria, and outcomes, data were synthesized qualitatively.
RESULTS
A total of 17 studies met the inclusion criteria, encompassing modalities such as computed tomography (CT), magnetic resonance imaging, dual-energy X-ray absorptiometry, and ultrasound. CT at the third lumbar vertebra level was most frequently used, exhibiting consistent prognostic values for pre- and post-transplant outcomes. However, considerable variability in cutoff values and sarcopenia definitions was observed. Emerging evidence also supports the prognostic relevance of muscle quality indicators, including muscle attenuation and fat infiltration.
CONCLUSION
CT and magnetic resonance imaging are the most robust imaging methods for sarcopenia diagnosis in patients with ESLD. Standardized diagnostic criteria incorporating muscle quality metrics are essential for improving prognostic accuracy and guiding clinical decision making in LT candidates. Such integration would also support the development of unified frameworks for sarcopenia assessment in transplantation practice.
Core Tip: Sarcopenia is a major prognostic factor in patients with end-stage liver disease awaiting liver transplantation. This systematic review highlights computed tomography and magnetic resonance imaging as the most accurate modalities for assessing skeletal muscle mass, especially at the third lumbar vertebra level. Despite this predictive value, the lack of standardized diagnostic criteria and cutoff values limits clinical application. This study emphasizes the emerging role of muscle quality indicators and calls for international consensus to improve risk stratification, guide clinical decision making, and enhance transplant outcomes.
