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Frailty at any BMI level increases liver transplant waitlist mortality

Frailty correlated with a twofold higher risk for waitlist mortality among both patients with and without obesity in need of liver transplantation, which increased to a threefold higher risk in those with class 2 or higher obesity, according to a study published in JAMA Surgery.

“Obesity is rising in prevalence among patients with end-stage liver disease, especially those seeking liver transplantation,” Christine E. Haugen, MD, from the Johns Hopkins University School of Medicine in Maryland, and colleagues wrote. “Alongside this rise is the increasing recognition of the association of sarcopenia with transplant-related outcomes, which is a dominant component of the frailty phenotype. Identification of frail patients may guide pretransplant interventions such as prehabilitation, which have been studied in candidates for kidney transplant.”

According to Haugen and colleagues, up to 25% of liver transplant candidates meet the condition of “frailty” — a state of decreased physiologic reserve and increased vulnerability to stressors — which has been associated with increased risks for waitlist mortality, hospitalization and depression.

The researchers enrolled 1,108 liver transplant candidates in the study, including 246 with class 1 obesity (BMI of 30-34.9 kg/m²) and 192 with class 2 (BMI of 35-39.9 kg/m²) or higher obesity (BMI of 40 kg/m² or higher). The researchers categorized 290 patients as frail.

Frailty correlated with a twofold higher risk for waitlist mortality among both patients with and without obesity in need of liver transplantation, which increased to a threefold higher risk in those with class 2 or higher obesity.

The prevalence of frailty, mean liver frailty index score, and median grip strength and median chair stand components of the liver frailty index were similar across all BMI categories; however, patients with class 2 or higher obesity had poorer median performance for balance testing compared with those with class 1 obesity and those without obesity.

Adjusted analyses showed that patients with class 1 obesity (adjusted HR = 1.12; 95% CI, 0.81-1.54) and those with class 2 or higher obesity (aHR = 1.16; 95% CI, 0.8-1.68) had a similar risk for waitlist mortality compared with those without obesity. Similarly, frailty correlated with a higher risk for waitlist mortality (aHR = 1.85; 95% CI, 1.36-2.5).

The correlation between frailty and waitlist mortality increased parallel with higher BMI from those without obesity (aHR = 1.54; 95% CI, 1.02-2.33) to those with class 1 obesity (aHR = 1.72; 95% CI, 0.99-2.99) to those with class 2 or higher obesity (aHR = 3.19; 95% CI, 1.75-5.82).

“Our data strongly support the incorporation of systematic frailty assessment with the [liver frailty index] in all patients with end-stage liver disease awaiting liver transplantation, which is particularly critical for individuals with stage 2 or greater obesity in whom frailty is associated with the highest risk of mortality,” Haugen and colleagues concluded. – by Talitha Bennett

Disclosures: Haugen reports she received grants from the National Institutes of Health. Please see the full study for all other authors’ relevant financial disclosures.