Jennifer C Lai1, Amy M Shui2, Andres Duarte-Rojo3,4, Daniel R Ganger5, Robert S Rahimi6, Chiung-Yu Huang2, Frederick Yao1, Matthew Kappus7, Brian Boyarsky8, Mara McAdams-Demarco9, Michael L Volk10, Michael A Dunn3,4, Daniela P Ladner11,12, Dorry L Segev8, Elizabeth C Verna13, Sandy Feng1. 1. Department of Medicine, University of California-San Francisco, San Francisco, California, USA. 2. Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA. 3. Center for Liver Diseases, Thomas A. Starzl Transplantation Institute, Pittsburgh, Pennsylvania, USA. 4. Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA. 5. Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, Illinois, USA. 6. Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White, Dallas, Texas, USA. 7. Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA. 8. Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. 9. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. 10. Division of Gastroenterology & Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, California, USA. 11. Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA. 12. Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA. 13. Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA.
Abstract
BACKGROUND AND AIMS: Frailty is a well-established risk factor for poor outcomes in patients with cirrhosis awaiting liver transplantation (LT), but whether it predicts outcomes among those who have undergone LT is unknown. APPROACH AND RESULTS: Adult LT recipients from 8 US centers (2012-2019) were included. Pre-LT frailty was assessed in the ambulatory setting using the Liver Frailty Index (LFI). "Frail" was defined by an optimal cut point of LFI ≥ 4.5. We used the 75th percentile to define "prolonged" post-LT length of stay (LOS; ≥12 days), intensive care unit (ICU) days (≥4 days), and inpatient days within 90 post-LT days (≥17 days). Of 1166 LT recipients, 21% were frail pre-LT. Cumulative incidence of death at 1 and 5 years was 6% and 16% for frail and 4% and 10% for nonfrail patients (overall log-rank p = 0.02). Pre-LT frailty was associated with an unadjusted 62% increased risk of post-LT mortality (95% CI, 1.08-2.44); after adjustment for body mass index, HCC, donor age, and donation after cardiac death status, the HR was 2.13 (95% CI, 1.39-3.26). Patients who were frail versus nonfrail experienced a higher adjusted odds of prolonged LT LOS (OR, 2.00; 95% CI, 1.47-2.73), ICU stay (OR, 1.56; 95% CI, 1.12-2.14), inpatient days within 90 post-LT days (OR, 1.72; 95% CI, 1.25-2.37), and nonhome discharge (OR, 2.50; 95% CI, 1.58-3.97). CONCLUSIONS: Compared with nonfrail patients, frail LT recipients had a higher risk of post-LT death and greater post-LT health care utilization, although overall post-LT survival was acceptable. These data lay the foundation to investigate whether targeting pre-LT frailty will improve post-LT outcomes and reduce resource utilization.
BACKGROUND AND AIMS: Frailty is a well-established risk factor for poor outcomes in patients with cirrhosis awaiting liver transplantation (LT), but whether it predicts outcomes among those who have undergone LT is unknown. APPROACH AND RESULTS: Adult LT recipients from 8 US centers (2012-2019) were included. Pre-LT frailty was assessed in the ambulatory setting using the Liver Frailty Index (LFI). "Frail" was defined by an optimal cut point of LFI ≥ 4.5. We used the 75th percentile to define "prolonged" post-LT length of stay (LOS; ≥12 days), intensive care unit (ICU) days (≥4 days), and inpatient days within 90 post-LT days (≥17 days). Of 1166 LT recipients, 21% were frail pre-LT. Cumulative incidence of death at 1 and 5 years was 6% and 16% for frail and 4% and 10% for nonfrail patients (overall log-rank p = 0.02). Pre-LT frailty was associated with an unadjusted 62% increased risk of post-LT mortality (95% CI, 1.08-2.44); after adjustment for body mass index, HCC, donor age, and donation after cardiac death status, the HR was 2.13 (95% CI, 1.39-3.26). Patients who were frail versus nonfrail experienced a higher adjusted odds of prolonged LT LOS (OR, 2.00; 95% CI, 1.47-2.73), ICU stay (OR, 1.56; 95% CI, 1.12-2.14), inpatient days within 90 post-LT days (OR, 1.72; 95% CI, 1.25-2.37), and nonhome discharge (OR, 2.50; 95% CI, 1.58-3.97). CONCLUSIONS: Compared with nonfrail patients, frail LT recipients had a higher risk of post-LT death and greater post-LT health care utilization, although overall post-LT survival was acceptable. These data lay the foundation to investigate whether targeting pre-LT frailty will improve post-LT outcomes and reduce resource utilization.
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