ArticleFrontiers in nutrition2026
Preoperative CT-derived skeletal muscle phenotypes, postoperative complication burden, and long-term survival after liver transplantation: a 90-day landmark mediation analysis.
Article in Frontiers in nutrition, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: CT-derived skeletal muscle index (SMI) and skeletal muscle density (SMD) may complement nutritional and functional assessment before liver transplantation, but pathways linking these body-composition phenotypes to long-term outcomes remain unclear. We evaluated whether cumulative 90-day postoperative complication burden was compatible with an intermediate pathway between lower preoperative SMI or SMD and long-term mortality. Methods: This single-center retrospective cohort used a postoperative day-90 landmark, restricting the primary analysis to recipients alive and under follow-up at day 90. SMI and SMD were analyzed separately, with the 90-day Comprehensive Complication Index (CCI) as the mediator and all-cause mortality during a prespecified 5-year post-landmark window as the outcome. Linear mediator and Cox outcome models adjusted for hepatocellular carcinoma, Eastern Cooperative Oncology Group performance status, and MELD 3.0. Percentile 95% confidence intervals (CIs) were obtained from 1,000 nonparametric bootstrap resamples. Results: Of 245 recipients screened, 205 entered the landmark cohort; 56 (27.3%) died during the prespecified 5-year post-landmark analysis window. Median analyzed follow-up was 3.33 years. For a 1-standard deviation decrease, the approximate natural indirect-effect hazard ratios (HRs) through CCI were 1.155 (95% bootstrap CI, 1.033-1.326) for SMI and 1.190 (1.062-1.382) for SMD. Natural direct-effect CIs included 1 for both exposures, whereas the total-effect CI excluded 1 for SMI but not SMD. Indirect-effect estimates were similar after replacing ECOG with age and delaying outcome follow-up to day 120, but were attenuated after CCI dichotomization. Conclusion: Lower preoperative SMI and SMD showed model-based approximate indirect effects through cumulative postoperative complication burden. These CT-derived muscle phenotypes may complement, but should not replace, comprehensive nutritional and functional assessment. The observational design and incompletely verifiable identification assumptions preclude strict causal or interventional interpretation.
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