TO THE EDITOR:
We appreciate the valuable comments provided by Xue
et al. on our submitted article. We assessed the associa-
tion between the perioperative decrease in the psoas
muscle index (PMI) and patient survival after living
donor liver transplantation (LDLT). Below are our
responses to the issues that they raised.
First, we agree with the need to pay special attention
to preoperative hematocrit and albumin levels when
the association between core muscle mass and patient
survival is assessed. Anemia is associated with a
decrease in muscle mass and strength, and hypoalbu-
minemia is considered a risk factor for loss of skeletal
Preoperative anemia and hypoalbumi-
nemia are highly prevalent in patients with chronic
liver disease, and previous reports have revealed that
low preoperative hematocrit and albumin levels are
associated with increased mortality after liver trans-
However, in this study, we
focused on the association between “perioperative
changes in core muscle mass” and patient survival. We
provide additional information from previous reports
in which the association between preoperative sarcope-
nia and patient survival after LT was evaluated.
Hematocrit and albumin levels were not signiﬁcantly
different preoperatively between the low-loss (PMI
211.7%) and high-loss (PMI < 211.7%) groups in
the study. We must assess changes in various factors,
including hematocrit and albumin levels, as Xue et al.
suggested, to determine which factors caused a
decrease in the PMI. This important question should
deﬁnitely be answered in subsequent studies.
Second, it is quite true that all known risk factors
the model to obtain the true inferences of a multivariate
regression analysis for the adjusted hazard ratio. We
observed that dialysis, early allograft dysfunction, all-cause
reoperation, and infection were postoperative complica-
tions associated with patient survival in a univariate Cox
regression analysis. We also compared other major com-
plications, including acute cellular rejection, biliary prob-
lems, hepatic vessel thrombosis, and de novo cancer
between the low-loss and high-loss groups, which were
considered to affect patient outcome. These complications
were comparable between the 2 groups during the follow-
up period and were not signiﬁcant with overall patient
mortality in a univariate Cox regression analysis and are
not included in Table 4. However, these factors are still
important and major concerns for patients who undergo
LT because previous studies have reported an association
between poor postoperative outcomes and acute rejection,
biliary and hepatic vascular problems, and cancer recur-
rence. In addition, as Xue et al. indicated, postoperative
development of gastrointestinal bleeding, pulmonary
complications, sepsis, and multiple-organ failure are con-
sidered independent factors for increased mortality after
LT, which we did not provide in the manuscript.
LT inevitably includes extensive surgery and post-
operative intensive care, which could induce acceler-
ated sarcopenic changes in vulnerable patients with
end-stage liver disease. Further studies are required to
validate whether these changes are modiﬁable and to
determine the factors related to perioperative sarco-
penic changes after LT.
Min Suk Chae, M.D.
Sang Hyun Hong, M.D., Ph.D.
Department of Anesthesiology and Pain Medicine
Seoul St. Mary’s Hospital
College of Medicine
The Catholic University of Korea
Seoul, Republic of Korea
1) Wang SL, Zhuang CL, Huang DD, Pang WY, Lou N, Chen
FF, et al. Sarcopenia adversely impacts postoperative clinical
Address reprint requests to Sang Hyun Hong, M.D., Ph.D.,
Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s
Hospital, College of Medicine, The Catholic University of Korea,
222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
Telephone: 182-2-2258-6157; FAX: 182-2-537-1951; E-mail:
Received March 19, 2018; accepted March 26, 2018.
2018 by the American Association for the Study of Liver
View this article online at wileyonlinelibrary.com.
Potential conflict of interest: Nothing to report.
LETTERS TO THE EDITOR
LETTERS TO THE EDITOR