*Purpose: Various methods exist for measuring body composition using computed tomography (CT) scans; however, it is unclear which components best predict post-liver transplantation (LT) outcomes. Thus, we decide to determine the association between CT-based body composition measurements and post-LT outcomes in a large North American cohort.

*Methods: This was a retrospective cohort of 454 deceased-donor LT recipients from 2009-2019 who underwent pre-LT abdominal CT scans in our tertiary hospital that included the third lumbar vertebral level. Body composition measurements were obtained, including sarcopenia, sarcopenic obesity, myosteatosis, visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and VAT/SAT ratio. Recipient characteristics and LT outcomes were ascertained from SRTR. Cox proportional hazard models were used to quantify associations of each measure with post-LT death and graft loss. Model discrimination was quantified using the Harrell C statistic. P values <.05 were considered significant.

*Results: In 454 recipients (median age, 57 years [IQR: 50, 62]; 160 women), sarcopenia was associated with a higher adjusted hazard of post-LT death (aHR, 1.6; 95% CI: 1.1, 2.4) but not graft loss (aHR, 1.4; 95% CI: 0.94, 2.1) (both, C: 0.64). Myosteatosis was not associated with death (aHR, 1.3; 95% CI: 0.86, 2.1) or graft loss (aHR, 1.1; 95% CI: 0.75, 1.7) (both, C: 0.64). Every 5 cm²/m² decrease in skeletal muscle index was associated with an increased hazard of death (aHR, 1.1; 95% CI: 1.0, 1.2; C: 0.64) and graft loss (aHR, 1.1; 95% CI: 1.0, 1.2; C: 0.65). Body mass index, VAT, SAT, and VAT/SAT ratio were not associated with death or all-cause graft loss (P > .05).

*Conclusions: Sarcopenia, as assessed on routine pre-LT CT scans, was the factor most strongly associated with post-LT death. Pre-LT CT is a valuable tool for identifying recipients at elevated risk.

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