Imaging-based assessment of sarcopenia in liver transplant candidates: A systematic review

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.

Keywords: Sarcopenia; End-stage liver disease; Liver transplantation; Imaging modalities; Pre-transplant risk stratification

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.