*Purpose: Sarcopenia is defined as loss of muscle mass and function. It has been reported as a significant risk factor for outcome after Liver transplantation (LT) as well as waitlist mortality in end-stage liver disease patients. Although there are various imaging modalities and measurement methods for diagnosing sarcopenia, the gold standard for evaluating sarcopenia in LT patients is not clear. The purpose of this study is to analyze the effect of sarcopenia on outcome in LT patients using previously known L3-skeletal muscle index (SMI) cut-off values and newly calculated thigh-SMI cut-off values.

*Methods: Two hundred eighteen patients who underwent living and deceased donor liver transplantation in our center from Sep 2018 to Dec 2020 were analyzed. L3-SMI and thigh-SMI were obtained by measuring preoperative computed tomography (CT) scan with semiautomatic software. For L3-SMI, the cut-off values reported in other previous studies were applied (50 in male, 39 in female). For Thigh SMI, the optimal cut-off value was calculated by obtaining the ROC curve for sarcopenia diagnosed as L3-SMI in our cohort.

*Results: The prevalence of sarcopenia diagnosed by L3-SMI in our cohort was 46% (101/218). Comparison between the sarcopenia group and the non-sarcopenia group by L3-SMI showed that the high MELD score and hospital stay were significantly higher in the sarcopenia group (P=0.045, P=0.015), and There was no significant difference in infection and rejection rates (P=0.675, P=0.670). Patient and graft survival rate in the sarcopenia group were significantly lower than non-sarcopenia group (P=0.001 and P=0.007). The cut-off values of thigh-SMI were obtained through the ROC curve. The results were 38.9 for female (AUC=0.856, P<0.001) and 48.2 for male (AUC=0.768, P<0.001). Both the patient and graft survival rates in the sarcopenia group by thigh-SMI were lower than in the non-sarcopenia group, but patient survival was not statistically significant (P=0.580, P=0.032). As a result of Cox analysis of LT recipient, sarcopenia by L3-SMI were confirmed as one of the independent prognostic factors for survival after LT (HR, 2.595; 95% CI, 0.999-6.740; P = 0.05).

*Conclusions: Sarcopenia by L3-SMI had an effect on clinical outcomes in LT patients and was confirmed as an independent prognostic factor for patient and graft survival. On the other hand, Thigh-SMI is unfavorable for predicting clinical outcome in LT patients. Therefore, L3-SMI can be a useful choice for sarcopenia evaluation in LT patients.

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