Frailty, Mortality, and Healthcare Utilization after Liver Transplantation: From the Multi-Center Functional Assessment in Liver Transplantation (FrAILT) Study.

BACKGROUND 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. METHODS Adults LT recipients from 8 U.S. centers (2012-2019) were included. Pre-LT frailty was assessed in the ambulatory clinic using the Liver Frailty Index (LFI). "Frail" was defined by an optimal cut point of LFI≥4.5. We used the 75%ile to define "prolonged" post-LT length of stay (LOS; ≥12d), intensive care unit (ICU; ≥4d) days, and inpatient days within 90 post-LT days (≥17d). RESULTS Of 1,166 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 non-frail patients (overall logrank 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 DCD status, the HR was 2.13 (95% CI 1.39-3.26). Patients who were frail versus non-frail experienced a higher adjusted odds of prolonged LT LOS [odds ratio (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% 1.25-2.37), and non-home discharge (OR 2.50, 95% 1.58-3.97). CONCLUSIONS Compared to non-frail patients, frail LT recipients had a higher risk of post-LT death and greater post-LT healthcare 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.