We read with great interest the article by Lu et al. [1] regarding the impact of myosteatosis on post–liver transplantation (LT) outcome in males transplanted for hepatocellular carcinoma (HCC). The authors reported a relatively low prevalence of myosteatosis (27.8% in males) using a gender-based definition (i.e., muscle attenuation less than 37.5 HU at the third lumbar vertebra of cross-sectional CT image for men). However, in our recently published meta-analysis [2] including 10 studies with 3316 HCC patients, the overall pooled prevalence of myosteatosis was estimated as high as 50% (95% confidence interval [CI] 35%–65%) [2]. This discrepancy could be attributed to the fact that Lu et al. [1] included mainly chronic hepatitis B–associated HCC patients, although all patients were Asians. Indeed, our meta-analysis showed that the prevalence of myosteatosis is significantly lower in Asian HCC patients, compared to the non-Asian HCC patients (pooled prevalence 45% vs. 69%, respectively, p = 0.02), whereas viral-associated HCC patients have significantly less frequently myosteatosis, compared to those with fatty or alcoholic liver disease–associated HCC (pooled prevalence 49% vs. 65% vs. 86%, respectively, p < 0.001). Interestingly, the authors [1] concluded that myosteatosis was not associated with post-LT outcome in females, although they did not provide which cutoff was used for definition of myosteatosis in this subgroup, although no clear explanation was given for this finding. In addition, they found no association between myosteatosis and hepatic encephalopathy although our meta-analysis [3] showed that cirrhotic patients with myosteatosis, compared to those without myosteatosis, have more frequently a previous history of hepatic encephalopathy (32% vs. 15%, p = 0.04) possibly related with the reduction of skeletal muscle capacity to remove ammonia. Finally, it would be interesting if the authors evaluated the impact of diabetes mellitus, which is an known factor associated with myosteatosis and poor prognosis after LT [3, 4], as well as if they compared the post-LT outcome of HCC patients with sarcopenia and myosteatosis/isolated myosteatosis versus those with isolated sarcopenia, as recent studies have shown that myosteatosis may be a more important factor, compared to sarcopenia, in the pre-LT setting of patients without HCC [5].

Nevertheless, Lu et al. [1] confirmed the predictive role of myosteatosis in HCC patients not only in the pre-LT setting [2] but also in the post-LT outcome [1], indicating the importance of including assessment of myosteatosis in the process for LT evaluation. However, their results [1] need validation in non-Asian populations, in which the aetiology of liver disease is more frequently metabolic and alcohol-related HCC.

我们饶有兴趣地阅读了 Lu 等人 [1] 的文章，该文章介绍了肌脂肪变性对肝细胞癌 （HCC） 移植男性肝移植 （LT） 后结局的影响。作者使用基于性别的定义（即男性横断面 CT 图像第三腰椎的肌肉衰减小于 37.5 胡）报告了肌脂肪变性的患病率相对较低（男性为 27.8%）。然而，在我们最近发表的荟萃分析[2]中，包括10项研究，涉及3316名肝细胞癌患者，肌脂肪变性的总体患病率估计高达50%（95%置信区间[CI] 35%-65%）[2]。这种差异可归因于以下事实：Lu et al. [1] 主要包括慢性乙型肝炎相关 HCC 患者，尽管所有患者都是亚洲人。事实上，我们的荟萃分析显示，与非亚洲 HCC 患者相比，亚洲 HCC 患者的肌脂肪变性患病率显著降低（汇总患病率分别为 45% 和 69%，p = 0.02），而病毒相关 HCC 患者的肌脂肪变性患病率显著降低，与脂肪性肝病或酒精性肝病相关的 HCC 患者相比（汇总患病率 49% vs. 65% vs. 86%， 分别，p < 0.001）。有趣的是，作者 [1] 得出结论，肌脂肪变性与女性的 LT 后结局无关，尽管他们没有提供用于定义该亚组肌脂肪变性的临界值，尽管没有对这一发现给出明确的解释。 此外，他们发现肌脂肪变性与肝性脑病之间没有关联，尽管我们的荟萃分析 [3] 显示，与没有肌脂肪变性的患者相比，患有肌脂肪变性的肝硬化患者更常有肝性脑病病史（32% vs. 15%，p = 0.04），可能与骨骼肌清除氨的能力降低有关。最后，如果作者评估了糖尿病的影响，糖尿病是与 LT 后肌脂肪变性和不良预后相关的已知因素 [3， 4]，以及如果他们比较了 HCC 患者伴肌少症和肌脂肪变性/孤立性肌脂肪变性与孤立性肌脂肪变性患者的 LT 后结局，那将是有趣的，因为最近的研究表明肌脂肪变性可能是一个更重要的因素， 与肌肉减少症相比，在无 HCC 患者的 LT 前期 [5]。

尽管如此，Lu 等人 [1] 证实了肌脂肪变性对 HCC 患者的预测作用，不仅在 LT 前情景 [2] 而且在 LT 后结局 [1] 中，表明在 LT 评估过程中包括肌脂肪变性评估的重要性。然而，他们的结果[1]需要在非亚洲人群中得到验证，在这些人群中，肝病的病因更常是代谢性和酒精相关性 HCC。