Frailty Score Predicts Outcomes Among Liver Transplant Candidates and Recipients
Christopher J. Sonnenday1, Michael Volk2, Michael J. Englesbe1
1Department of Surgery, University of Michigan, Ann Arbor, MI; 2Department of Medicine, University of MIchigan, Ann Arbor, MI
Appropriate organ allocation must balance minimizing waitlist mortality and maximizing post-transplant outcomes. While MELD predicts waitlist death, additional metrics are needed to identify transplant candidates at risk for poor outcomes. Frailty, a syndrome of decreased physiologic reserve associated with adverse health outcomes, may provide a novel measure of risk stratification among candidates for transplantation. Single center prospective trial of patients referred for transplant evaluation and assessed for quality of life (sf36), depression, and frailty. The frailty instrument has 5 elements (walking speed, grip strength, unintentional weight loss, self-reported exhaustion, and weekly physical activity). Each element has criteria that indicate frailty, such that each patient has a frailty score between 0 (not frail) and 5 (highly frail). The frailty instrument has been validated in geriatrics but not studied in liver disease. Clinical data and outcomes were recorded for all patients, and deaths confirmed via the SSDMF. Since 2009, 502 subjects have been enrolled in the clinical trial, with median follow-up of 21 months (range 3-45 mos). Frailty was normally distributed among study subjects, and not correlated with age, sex, BMI, cause of liver disease, or number of comorbidities. Frailty was weakly positively correlated with MELD score (=0.25, P<0.01), but mean MELD score among high frailty (3-5) and low frailty (0-2) subjects was equivalent (12.5). High frailty was associated with higher depression (6 vs. 3, P<0.01), and decreased quality of life (sf36 32 vs. 53, P<0.01). Pre-transplant mortality was increased among high frailty patients (HR=2.7, P=0.02), and interacted with high MELD to produce poor pre-transplant survival (median survival, high frailty with MELD>15 = 6 mos). Among 73 patients in the study who underwent transplantation, 1-year survival was equivalent among high frailty and low frailty patients (90%). However, high frailty patients had higher rates of biliary complications (33 vs 20%), renal failure (29 vs 14%), discharge to a skilled nursing facility (20 vs 9.3%) and 90-day readmission rates (67 vs 43%). Reoperation rates increased in a linear fashion from 8% for nonfrail patients (score 0) to 100% in highly frail patients (score 5). Frailty is a useful risk stratification domain for liver transplant candidates associated with decreased pre-transplant survival and increased post-transplant complications and resource utilization. Given the equivalent post-transplant survival among high frailty patients, further study is needed to determine if high frailty patients with a MELD>15 would benefit from expedited allocation.
The following people have nothing to disclose: Christopher J. Sonnenday, Michael Volk, Michael J. Englesbe