More Severe Deficits in Performance Status at Time of Liver Transplant is Associated With Significantly Higher Risk of Death Following Liver Transplantation

Abstract

Goal: To evaluate the impact of Karnofsky Performance Status score (KPSS) at the time of liver transplantation (LT) on post-LT survival. Background: While the Model for End-Stage Liver Disease (MELD) score is used to prioritize individuals for LT, it does not specifically incorporate functional status into patient assessment for LT. Methods: Using 2005 to 2016 United Network for Organ Sharing data, all adults (age 18 y and above) undergoing LT were identified. The association of KPSS at the time of LT (KPSS 1: functional status 80% to 100%, KPSS 2: 60% to 70%, KPSS 3: 40% to 50%, KPSS 4: 10% to 30%) with post-LT survival was evaluated using Kaplan-Meier methods and adjusted multivariate logistic regression models. Results: Among 66,397 LT recipients (68% male, 72% non-Hispanic white, 22% hepatocellular carcinoma, median age: 55 to 57), women were more likely to be KPSS 4 at the time of LT compared with men (27.95% vs. 22.79%; P<0.001) and African Americans (25.43% vs. 23.03%; P<0.001) and Hispanics (31.69% vs. 23.03%; P<0.001) were more likely to be KPSS 4 than non-Hispanic whites. Worse KPSS at LT correlated with higher post-LT mortality [compared with KPSS 1: Hazard Ratio (HR) for KPSS 2: 1.16, 95% confidence interval (CI): 1.10-1.22; HR for KPSS 3: 1.40; 95% CI: 1.32-1.49; HR for KPSS 4: 1.67; 95% CI: 1.55-1.79]. This increased mortality seen with worse KPSS was observed among all liver disease etiologies and in patients with and without hepatocellular carcinoma. Conclusions: Worse functional status at the time of LT is strongly associated with higher risk of mortality following LT, emphasizing the importance of optimizing performance status in the preoperative period.

Functional Status at Liver Transplant Waitlisting Correlates With Greater Odds of Encephalopathy, Ascites, and Spontaneous Bacterial Peritonitis

“…Thus our observation of the association between poor performance status and higher odds of decompensating events, may simply reflect that underlying worsening of liver disease, which leads to development of decompensation and complications itself drives the gradual decline in performance status. Furthermore, although our present study focuses specifically on waitlist outcomes, previously studies have demonstrated that worse FS also correlates with lower survival after LT. 29 For its strengths, the study assesses a large, national, diverse patient population over 12 years and uses a frailty instrument commonly and inexpensively used across specialties, including oncology, thereby providing a common framework for multidisciplinary care as transplant evaluation often involves. Among its limitations, the crosssectional design of the study precludes establishment of causality.…”

Introducing EL‐FIT (Exercise and Liver FITness): A Smartphone App to Prehabilitate and Monitor Liver Transplant Candidates

“…( 3,4 ) Frailty is present in 18% to 25% of patients with end‐stage liver disease (ESLD), and it is associated with nearly twice the mortality of reference populations as well as increased hospital admission, waitlist mortality, posttransplant complications, and health care costs. ( 3,5‐7 ) Frailty is also a progressive condition for patients on the waiting list as its prevalence doubles from the time of listing to the time of LT. ( 8,9 )…”

Physiologic Reserve Assessment and Application in Clinical and Research Settings in Liver Transplantation

“…(C) Poor performance on the KPS and ADL is associated with significantly higher mortality before LT; poor performance on the ECOG is associated with significantly higher mortality after LT. Adapted from Tandon et al, ( 5 ) McCabe et al, ( 7 ) Jacob et al, ( 12 ) and Tapper et al ( 16 ) KPS, Karnofsky performance status; R, reliant on others; SC, able to perform self‐care.…”

“…In patients awaiting LT, a lower KPS score is associated with the increased prevalence and severity of ascites and encephalopathy. ( 7 ) Those in the KPS B (hazard ratio [HR], 1.14) and KPS C categories (HR, 1.63) had an increased risk of mortality when compared with those in the KPS A category. ( 6 ) Those with lower KPS scores after LT are more likely to have a longer length of stay (LOS), require readmissions, ( 7 ) and need longer intubation time.…”

“…( 7 ) Those in the KPS B (hazard ratio [HR], 1.14) and KPS C categories (HR, 1.63) had an increased risk of mortality when compared with those in the KPS A category. ( 6 ) Those with lower KPS scores after LT are more likely to have a longer length of stay (LOS), require readmissions, ( 7 ) and need longer intubation time. ( 8 ) Poor performance status at the time of LT is associated with lower graft and patient survival in patients with KPS B and KPS C. ( 9 ) KPS improved in up to 25% of patients at 1 year following transplant.…”