Cutoff Value of Psoas Muscle Area as Reduced Muscle Mass and Its Association with Acute Pancreatitis in China

Figures & data

Figure 1 Flow chart of the study.

Table 1 Modified Marshall Scoring System for Organ Dysfunction

Organ System	Score
	0	1	2	3	4
Respiratory (PaO2/FiO2)	>400	301–400	201–300	101–200	≤101
Renal
(serum creatinine, µmol/l)	≤134	134–169	170–310	311–439	>439
(serum creatinine, mg/dl)	<1.4	1.4–1.8	1.9–3.6	3.6–4.9	>4.9
Cardiovascular (systolic blood pressure, mm Hg, off inotropes)	>90	<90, fluid responsive	<90, not fluid responsive	<90, pH<7.3	<90, pH<7.2
For non-ventilated patients, the FiO2can be estimated from below:
Supplemental oxygen (l/min)	FiO2 (%)
Room air	21
2	25
4	30
6–8	40
9–10	50

Notes: A score of two or more in any system defines the presence of organ failure. Reproduced from Gut. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. 62(1):102–111, Copyright (2013), with permission from BMJ Publishing Group Ltd.²

Table 2 Updating Charlson Comorbidity Index and Score

Comorbidity	Score
Myocardial infarction	0
Congestive heart failure	2
Peripheral vascular disease	0
Cerebrovascular disease	0
Dementia	2
Chronic pulmonary disease	1
Rheumatologic disease	1
Peptic ulcer disease	0
Mild liver disease	2
Diabetes without chronic complications	0
Diabetes with chronic complications	1
Hemiplegia or paraplegia	2
Renal disease	1
Any malignancy, including leukemia and lymphoma	2
Moderate or severe liver disease	4
Metastatic solid tumor	6
AIDS/HIV	4
Maximum comorbidity score	24

Notes: Adapted from Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173(6):676–682, with permission from Oxford University Press.⁸

Figure 2 Cross-sectional CT images at the L3 vertebra level. The psoas muscle borders were manually outlined.

Table 3 Characteristics of 269 Patients with AP

	Total n = 269	Mild n = 190 (70.6%)	Moderately Severe n = 55 (20.4%)	Severe n = 24 (8.9%)
Gender, n(%)
Men	158(58.7)	114(72.2)	28(17.7)	16(10.1)
Women	111(41.3)	76(68.5)	27(24.3)	8(7.2)
Age, years^a	49.0(37.0–64.0)	48.5(37.0–62.3)	48.0(37.0–64.0)	51.0(38.8–67.0)
AP history, n(%)
No	193(71.7)	136(70.5)	41(21.2)	16(8.3)
Yes	76(28.3)	54(71.1)	14(18.4)	8(10.5)
Comorbidity score^a	0(0–0)	0(0–0)	0(0–0)	0(0–0)
Aetiology, n(%)^b
Biliary	69(25.7)	52(27.4)	11(20.0)	6(25.0)
Hypertriglyceridemic	47(17.5)	27(14.2)	13(23.6)	7(29.2)
Alcoholic	78(29.0)	56(29.5)	17(30.9)	5(20.8)
Other	75(27.9)	55(28.9)	14(25.5)	6(25.0)
Infectious complications, n(%)	18(6.7)	0	7(12.7)	11(45.8)
Local complications, n(%)	45(16.7)	0	37(67.3)	8(33.3)
Splenic vein thrombosis, n (%)	7 (2.6)	0	6 (10.9)	1 (4.8)
Organ failure, n(%)	46(17.1)	0	22(40.0)	24(100.0)
ICU admission, n (%)	10 (3.7)	0	0	10 (41.7)
Death, n(%)	1(0.4)	0	0	1(4.2)
LOS, days^a	9.0(7.0–12.5)	9.0 (6.0–11.0)	10.0(8.0–14.0)	16.0(8.3–20.8)
Hospital costs, RMB^a	9273.2(6520.9–14,840.0)	8251.5(5811.0–12,242.7)	11,214.5(8040.0–20,723.0)	35,154.7(17,480.8–113,827.0)

Notes: ^aValues are in median (IQR). ^bDistribution of aetiologies among each group.

Abbreviations: LOS, length of hospital stay; AP, acute pancreatitis.

Table 4 Association Between Measured Variables and Severity of AP

	Total n = 269	Mild n = 190 (70.6%)	Moderately Severe n = 55 (20.4%)	Severe n = 24 (8.9%)	p
BMI, kg/m^2 a	25.6 ± 4.1	25.4 ± 4.1	25.9 ± 4.0	27.1 ± 4.4	0.123
PMA, cm^2	15.28 (11.00–21.09)	16.09 (12.02–21.73)	14.33 (9.52–20.00)	11.78 (9.10–19.42)	0.045
PMI, cm^2/m^2	5.43 (4.19–7.23)	5.52 (4.37–7.37)	4.84 (3.67–6.48)	4.5 (3.43–6.46)	0.034
Hemoglobin, g/L	148.60 ± 23.94	148.82 ± 20.65	145.93 ± 25.64	152.83 ± 39.98	0.244
NLR	7.75 (4.62–12.98)	6.63 (4.23–12.00)	10.38 (7.52–14.89)	10.84 (5.49–17.09)	0.001
CRP/Alb, mg/g	1.55 (0.30–3.55)	0.98 (0.15–2.89)	2.35 (0.96–4.59)	5.11 (2.93–8.23)	<0.001
CsCa, mmol/L	2.19 (2.10–2.25)	2.22 (2.13–2.26)	2.14 (2.05–2.26)	2.04 (1.76–2.19)	<0.001
Triglyceride	2.41 (1.17–6.62)	2.10(1.07–5.93)	4.08(1.42–11.68)	4.85(1.66–14.13)	0.029
Amylase	352.3(134.5–870.4)	350.0(121.2–991.8)	309.5(135.9–718.3)	582.0(321.8–1503.5)	0.098
Lipase	1742.4(513.0–4630.0)	1761.4(483.6–4772.7)	1278.0(516.4–3364.6)	2000.0(1427.2–4845.8)	0.303

Notes: ^aMean ±standard deviation, LSD test, others median (IQR), Kruskal–Wallis H-test.

Abbreviations: BMI, body mass index; PMA, psoas muscle area; PMI, psoas muscle index; NLR, neutrophil-to-lymphocyte ratio; CRP, C-reactive protein; Alb albumin; CsCa, corrected serum calcium.

Figure 3 Values of PMA (A) and PMI (B) by sex.

Figure 4 Distribution and post hoc LSD of PMA and PMI according to age in men (A and B) and women (C and D).

Figure 5 A negative correlation between PMA/PMI and age was observed in men (A and B) and women (C, D).

Table 5 Validation of the Estimated Cutoff of PMA

PMA, cm^2	Men, n = 158			Women, n = 112
	≤11.50 (n = 10)	>11.50 (n = 148)	p	≤8.22 (n = 21)	>8.22 (n = 91)	p
Infectious complications, n(%)	2(20)	8(5.4)	0.124	4(19.0)	4(4.4)	0.039
Local complications, n(%)	4(40.0)	15(10.1)	0.020	9(42.9)	17(18.7)	0.041
Splenic vein thrombosis, n (%)	2 (20.0)	3 (2.0)	0.033	2 (9.5)	0	0.034
Organ failure, n (%)	5 (50.0)	26 (17.6)	0.026	6 (28.6)	9 (9.9)	0.035
ICU admission, n (%)	1 (10.0)	7 (4.7)	1.000	1 (4.8)	1 (1.1)	0.341
LOS, days	8.5 (6.5–17.3)	9.0 (6.0–11.0)	0.494	13.0 (10.0–16.0)	10.0 (7.0–12.0)	0.005
Total hospital cost, RMB	14169.3 (8751.4–27,362.4)	8375.0 (5833.4–13,596.0)	0.036	13,115.8 (8678.3–21,981.5)	9966.8 (7072.4–14,817.2)	0.051

Abbreviations: PMA, psoas muscle area; LOS, length of hospital stay.

Table 6 Validation of the Estimated Cutoff of PMI

PMI, cm^2/m^2	Men, n = 158			Women, n = 112
	≤3.85 (n = 9)	>3.85 (n = 149)	p	≤3.20 (n = 20)	>3.20 (n = 92)	p
Infectious complications, n (%)	2 (22.2)	8 (5.4)	0.102	2 (10.0)	6 (6.5)	0.632
Local complications, n (%)	4 (44.4)	15(10.1)	0.013	8(40.0)	18 (19.6)	0.076
Splenic vein thrombosis, n (%)	2 (22.2)	3 (2.0)	0.026	1 (5.0)	1 (1.1)	0.372
Organ failure, n (%)	4 (44.4)	27 (18.1)	0.075	5 (25.0)	10 (10.9)	0.140
ICU admission, n (%)	1 (11.1)	7 (4.7)	0.381	0	2 (2.2)	1.000
LOS, days	8.0 (6.0–16.5)	9.0 (6.0–11.5)	0.898	13.0 (10.0–15.8)	10.0 (7.0–12.0)	0.024
Total hospital cost, RMB	13644.9 (8699.4–30,620.1)	8421.8 (5853.9–13,949.6)	0.072	13,079.5 (7084.6–22,057.7)	10,009.2 (7190.8–14,760.0)	0.118

Abbreviations: PMI, psoas muscle index; LOS, length of hospital stay.

Table 7 Efficacy of PMA/PMI in Predicting the Severity and Complications of Men with AP

Content	Parameter	AUC (95% CI)	Sensitivity (%)	Specificity (%)	Threshold	Sensitivity (%)^a	Specificity (%)^a	Threshold^a	p^b
MSAP+SAP	PMA, cm^2	0.585 (0.504–0.663)	15.91	96.49	≤11.50	70.45	45.61	≤21.21	0.9238
	PMI, cm^2/m^2	0.586 (0.505–0.664)	15.91	97.37	≤3.85	68.18	53.51	≤6.68
SAP	PMA, cm^2	0.638(0.558–0.713)	25.00	95.07	≤11.50	37.50	93.66	≤12.25	0.3269
	PMI, cm^2/m^2	0.625 (0.545–0.701)	31.25	96.48	≤3.85	50.00	81.69	≤5.01
Infectious complications	PMA, cm^2	0.716(0.639–0.785)	20.00	93.92	≤11.50	70.00	81.08	≤14.82	0.2626
	PMI, cm^2/m^2	0.700 (0.622–0.770)	20.00	95.27	≤3.85	70.00	81.76	≤5.01
Local complications	PMA, cm^2	0.580(0.499–0.658)	21.05	92.81	≤11.50	100.00	22.30	≤24.77	0.4531
	PMI, cm^2/m^2	0.591 (0.511–0.669)	26.32	96.40	≤3.85	31.58	91.37	≤4.49
Splenic vein thrombosis	PMA, cm^2	0.664(0.585–0.737)	40.00	95.42	≤11.50	60.00	80.39	≤14.55	0.4693
	PMI, cm^2/m^2	0.681 (0.602–0.753)	40.00	95.42	≤3.85	60.00	90.20	≤4.49
Organ failure	PMA, cm^2	0.600(0.519–0.677)	16.13	95.28	≤11.50	54.84	66.14	≤17.93	0.4824
	PMI, cm^2/m^2	0.590 (0.509–0.668)	12.90	96.85	≤3.85	70.97	51.97	≤6.68
ICU admission	PMA, cm^2	0.587(0.506–0.664)	12.50	93.33	≤11.50	37.50	92.00	≤12.25	0.5637
	PMI, cm^2/m^2	0.596 (0.515–0.673)	12.50	94.67	≤3.85	50.00	80.00	≤5.01

Notes: ^aCutoff values were determined by Youden’s index. ^bPairwise comparison of ROC curves of PMA and PMI. AUC is the area under the ROC curve, and the range of 95% CI is shown.

Abbreviations: AUC, area under the curve; CI, confidence interval; ROC, receiver operating curve; MSAP, moderately severe acute pancreatitis;SAP, severe acute pancreatitis; PMA, psoas muscle area; PMI, psoas muscle index.

Table 8 Efficacy of PMA/PMI in Predicting the Severity and Complications of Women with AP

Content	Parameter	AUC (95% CI)	Sensitivity (%)	Specificity (%)	Threshold	Sensitivity (%)^a	Specificity (%)^a	Threshold^a	p^b
MSAP+SAP	PMA, cm^2	0.645(0.549–0.734)	31.43	85.53	≤8.22	85.71	43.42	≤12.04	0.4027
	PMI, cm^2/m^2	0.633(0.536–0.723)	28.57	86.84	≤3.20	57.14	73.68	≤3.78
SAP	PMA, cm^2	0.684(0.589–0.769)	25.00	80.58	≤8.22	100.00	40.78	≤11.78	0.9785
	PMI, cm^2/m^2	0.683(0.588–0.768)	25.00	82.52	≤3.20	75.00	67.96	≤3.76
Infectious complications	PMA, cm^2	0.691(0.597–0.775)	50.00	83.65	≤8.22	62.50	74.04	≤9.04	0.0435
	PMI, cm^2/m^2	0.641(0.545–0.729)	25.00	82.69	≤3.20	100.00	32.69	≤4.82
Local complications	PMA, cm^2	0.597(0.500–0.688)	34.62	82.56	≤8.22	42.31	82.56	≤8.27	0.8717
	PMI, cm^2/m^2	0.599 (0.502–0.691)	30.77	87.21	≤3.20	50.00	75.58	≤3.60
Splenic vein thrombosis	PMA, cm^2	0.848(0.768–0.909)	100.00	83.64	≤8.22	100.00	83.64	≤8.11	0.6010
	PMI, cm^2/m^2	0.795 (0.709–0.866)	50.00	88.18	≤3.20	100.00	70.91	≤3.60
Organ failure	PMA, cm^2	0.769(0.680–0.843)	40.00	83.51	≤8.22	86.67	68.04	≤9.56	0.5247
	PMI, cm^2/m^2	0.759 (0.670–0.8358)	33.33	80.41	≤3.20	86.67	71.13	≤3.78
ICU admission	PMA, cm^2	0.773(0.684–0.847)	50.00	81.82	≤8.22	100.00	72.73	≤9.04	0.0008
	PMI, cm^2/m^2	0.705 (0.611–0.787)	50.00	75.45	≤3.20	100.00	65.45	≤3.76

Notes: ^aCutoff values were determined by Youden’s index. ^bPairwise comparison of ROC curves of PMA and PMI. AUC is the area under the ROC curve, and the range of 95% CI is shown.

Abbreviations: AUC, area under the curve; CI, confidence interval; ROC, receiver operating curve; MSAP, moderately severe acute pancreatitis; SAP, severe acute pancreatitis; PMA, psoas muscle area; PMI, psoas muscle index.

Figure 6 Receiver operating characteristic (ROC) analysis of the predictive efficiency of PMA and PMI by sex. Solid blue lines represent PMA, dashed green lines represent PMI.(A) Moderately severe acute pancreatitis + severe acute pancreatitis in men, (B) Moderately severe acute pancreatitis + severe acute pancreatitis in women, (C) Severe acute pancreatitis in men, (D) Severe acute pancreatitis in women, (E) Infectious complications in men, (F) Infectious complications in women, (G) Local complications in men, (H) Local complications in women, (I) Splenic vein thrombosis in men, (J) Splenic vein thrombosis in women, (K) Organ failure in men, (L) Organ failure in women, (M) ICU admission in men, (N) ICU admission in women.

Table 9 Univariate and Multivariate Regression Analysis of MSAP and SAP

	Univariate OR (95% CI)	p	Multivariate aOR (95% CI)	p
Gender
Men	0.838(0.493–1.424)	0.514	1.100(0.570–2.121)	0.777
Women	1 (ref)
Age, years
<49	0.975(0.577–1.648)	0.925	0.990(0.484–2.022)	0.977
≥49	1 (ref)
BMI, kg/m^2				0.325
<18.5	0.545(0.141–2.106)	0.379	0.218(0.035–1.361)	0.103
18.5–23.9	1 (ref)
24–28	0.980(0.517–1.857)	0.951	1.030(0.459–2.313)	0.942
>28	1.099(0.531–2.277)	0.799	1.309(0.507–3.381)	0.578
PMA, cm^2
Low PMA	4.018(1.859–8.681)	<0.001	5.639(2.038–15.607)	0.001
High PMA	1 (ref)
NLR
<7.75	0.298(0.169–0.524)	<0.001	0.422(0.219–0.813)	0.010
≥7.75	1 (ref)
CRP/Alb, mg/g
<1.55	0.301(0.170–0.533)	<0.001	0.363(0.188–0.704)	0.003
≥1.55	1 (ref)
CsCa, mmol/L
<2.11	4.003(2.232–7.179)	<0.001	3.796(1.913–7.534)	<0.001
≥2.11	1 (ref)
Comorbidity score
0	1 (ref)
≥1	1.254(0.643–2.444)	0.506	1.503(0.636–3.551)	0.353

Abbreviations: OR, odds ratio; aOR, adjusted odds ratio; CI, confidence intervals;BMI, body mass index; PMA, psoas muscle area; NLR, neutrophil-to-lymphocyte ratio; CRP, C-reactive protein; Alb albumin; CsCa, corrected serum calcium.

Table 10 Univariate and Multivariate Regression Analysis of SAP (Adjust for NLR, CRP/Alb, and Corrected Serum Calcium)

	Univariate OR (95% CI)	p	Multivariate aOR (95% CI)	p
Gender
Men	1.451(0.598–3.518)	0.410
Women	1 (ref)
Age, years
<49	0.839(0.362–1.946)	0.683
≥49	1 (ref)
BMI, kg/m^2
<18.5	0.756(0.085–6.748)	0.802
18.5–23.9	1 (ref)
24–28	1.308(0.468–3.650)	0.609
>28	0.977(0.283–3.368)	0.971
PMA, cm^2
Low PMA	2.933(1.066–8.072)	0.037	3.205(1.034–9.934)	0.044
High PMA	1 (ref)
NLR
<7.75	0.379(0.152–0.947)	0.038	0.662(0.245–1.788)	0.416
≥7.75	1 (ref)
CRP/Alb, mg/g
<1.55	0.130(0.038–0.449)	0.001	0.165(0.046–0.592)	0.006
≥1.55	1 (ref)
CsCa, mmol/L
<2.11	4.600(1.937–10.924)	0.001	3.981(1.554–10.201)	0.004
≥2.11	1 (ref)
Comorbidity score
0	1 (ref)
≥1	0.914(0.298–2.806)	0.875

Abbreviations: OR, odds ratio; aOR, adjusted odds ratio; CI, confidence intervals; BMI, body mass index; PMA, psoas muscle area; NLR, neutrophil-to-lymphocyte ratio; CRP, C-reactive protein; Alb albumin; CsCa, corrected serum calcium.

Table 11 Univariate and Multivariate Regression Analysis of SAP (Adjust for Gender, Age, BMI, NLR, CRP/Alb, Corrected Serum Calcium, and Comorbidity Score)

	Univariate R (95% CI)	p	Multivariate aOR (95% CI)	p
Gender
Men	1.451(0.598–3.518)	0.410	2.573(0.838–7.900)	0.099
Women	1 (ref)
Age, years
<49	0.839(0.362–1.946)	0.683	0.574(0.197–1.674)	0.310
≥49	1 (ref)
BMI, kg/m^2
<18.5	0.756(0.085–6.748)	0.802	0.620(0.051–7.529)	0.707
18.5–23.9	1 (ref)
24–28	1.308(0.468–3.650)	0.609	1.083(0.303–3.868)	0.903
>28	0.977(0.283–3.368)	0.971	0.884(0.204–3.824)	0.869
PMA, cm^2
Low PMA	2.933(1.066–8.072)	0.037	3.995(1.077–14.820)	0.038
High PMA	1 (ref)
NLR
<7.75	0.379(0.152–0.947)	0.038	0.625(0.221–1.767)	0.375
≥7.75	1 (ref)
CRP/Alb, mg/g
<1.55	0.130(0.038–0.449)	0.001	0.161(0.044–0.592)	0.006
≥1.55	1 (ref)
CsCa, mmol/L
<2.11	4.600(1.937–10.924)	0.001	4.467(1.637–12.191)	0.003
≥2.11	1 (ref)
Comorbidity score
0	1 (ref)
≥1	0.914(0.298–2.806)	0.875	1.006(0.257–3.940)	0.993

Abbreviations: OR, odds ratio; aOR, adjusted odds ratio; CI, confidence intervals; BMI, body mass index; PMA, psoas muscle area; NLR, neutrophil-to-lymphocyte ratio; CRP, C-reactive protein; Alb, albumin; CsCa, corrected serum calcium.

Table 12 Cutoff Values Determined by CT in Different Studies

Study	Number of Subjects, n (Women)	Population	Age Range, Years	Weight, Women/Men^a	Height, Women/Men^b	BMI, Women/Men^c	PMA Cutoffs, cm^2		PMI Cutoffs, cm^2/m^2		Cutoffs Derivation Method
							Men	Women	Men	Women
France^Citation16,d	256(60)	PWLC	53 ± 10.5^e	74.4	171.2	25.3	15.61	14.64	–	–	Youden index
India^Citation14	2002(694)	PWCD	18–50	–	–	–	11.64	7.92	3.89	3.20	Mean − 2 SDs
Turkey^Citation15,f	88(40)	PKD	20–40	63.4/76.4	162.3/175.5	23.9/25.3	9.46	7.14	3.20	2.87	5th percentile
	270 (136)	PKD	20–60	67.0/75.8	161.0/169.6	25.4/26.4	7.37	5.57	2.63	2.02	5th percentile
Canada^Citation17	125(66)	PWCD	20–39	–	–	–	22.0	11.1	–	–	2.5th percentile
Japan^Citation19,d	31(10)	PWGC	35–83	–	–	19.3	–	–	3.6	2.9	Mean − 1 SD
Japan^Citation20,g	293(130)	PWCD	≤50	49.9–54.6/65.4–74.1	157.6–158.3/171.1–172.2	19.9–22.0/22.0–25.2	–	–	3.30	1.69	Mean − 2 SDs
	293(130)	PWCD	≤50	49.9–54.6/65.4–74.1	157.6–158.3/171.1–172.2	19.9–22.0/22.0–25.2	–	–	3.74	2.29	5th percentile
Korea^Citation21,h	1422(872)	PWCD	20–89	56.6/71.5	158.0/171.0	22.8/24.5	–	–	3.31–5.92	1.48–4	Mean − 2 SDs
Japan^Citation22	110(49)	PWCD	≤54	53.9/74.9	157.6/171.9	21.7/25.3	–	–	4.24	2.5	Mean − 2 SDs
Turkey^Citation23,f	482(214)	PLD	18–40	61.4/76.5	169.3/175.4	23.6/24.8	–	–	5.4	3.6	5th percentile
			18–40				–	–	4.6	2.7	Mean − 2 SDs
	601(275)	PLD	18–60	63.1/76.7	161.3/174.9	24.3/25.0	–	–	5.3	3.6	5th percentile
			18–60				–	–	4.4	2.7	Mean − 2 SDs
Japan^Citation24	391 (-)	PLD	20–49	–	–	–	–	–	6.36	3.92	Mean − 2 SDs
China^i	83 (30)	PWAP	23–48	64.8/76.2	160.8/172.8	25.0/25.5	11.50	8.22	3.85	3.20	Mean − 1.64 SDs

Notes: ^aMean/Median weight (kg). ^bMean/Median height (cm). ^cMean/Median BMI (kg/m²). ^dNo gender stratification in BMI. ^eMean ± SD. ^fStudies investigating cutoff values in the whole and young population separately. ^gAverage value of each decade. ^hCutoffs were described for each decade of the population. ⁱPresent study.

Abbreviations: PKD, potential kidney donor; PLD, potential liver donor; PWCD, patients without known chronic disease; PWLC, patients with liver cirrhosis; PWGC, patients with advanced gastric cancer; PWAP, patients with acute pancreatitis; PMA, psoas muscle area; PMI, psoas muscle index; BMI, body mass index; SD, standard deviation.

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