A Decline in Functional Status While Awaiting Liver Transplantation is Predictive of Increased Post-transplantation Mortality

Overview

Journal HPB (Oxford)

Publisher Elsevier

Specialty Gastroenterology

Date 2021 Nov 13

PMID 34772623

Authors

Dmitri Bezinover

Nathaniel R Geyer

Jessica Dahmus

Vernon M Chinchilli

Jonathan G Stine

Affiliations

Soon will be listed here.

Abstract

Background: Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes.

Methods: Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS.

Results: Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival.

Conclusion: A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.

References

Thuluvath P, Thuluvath A, Savva Y . Karnofsky performance status before and after liver transplantation predicts graft and patient survival. J Hepatol. 2018; 69(4):818-825. DOI: 10.1016/j.jhep.2018.05.025. View

Roman E, Torrades M, Nadal M, Cardenas G, Nieto J, Vidal S . Randomized pilot study: effects of an exercise programme and leucine supplementation in patients with cirrhosis. Dig Dis Sci. 2014; 59(8):1966-75. DOI: 10.1007/s10620-014-3086-6. View

Jacob M, Copley L, Lewsey J, Gimson A, Rela M, van der Meulen J . Functional status of patients before liver transplantation as a predictor of posttransplant mortality. Transplantation. 2005; 80(1):52-7. DOI: 10.1097/01.tp.0000163292.03640.5c. View

Ritland S, PETLUND C, Knudsen T, Skrede S . Improvement of physical capacity after long-term training in patients with chronic active hepatitis. Scand J Gastroenterol. 1983; 18(8):1083-7. DOI: 10.3109/00365528309181845. View

Macias-Rodriguez R, Ilarraza-Lomeli H, Ruiz-Margain A, Ponce-de-Leon-Rosales S, Vargas-Vorackova F, Garcia-Flores O . Changes in Hepatic Venous Pressure Gradient Induced by Physical Exercise in Cirrhosis: Results of a Pilot Randomized Open Clinical Trial. Clin Transl Gastroenterol. 2016; 7(7):e180. PMC: 5543482. DOI: 10.1038/ctg.2016.38. View

Yoo H, Patt C, Geschwind J, Thuluvath P . The outcome of liver transplantation in patients with hepatocellular carcinoma in the United States between 1988 and 2001: 5-year survival has improved significantly with time. J Clin Oncol. 2003; 21(23):4329-35. DOI: 10.1200/JCO.2003.11.137. View

Zenith L, Meena N, Ramadi A, Yavari M, Harvey A, Carbonneau M . Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol. 2014; 12(11):1920-6.e2. DOI: 10.1016/j.cgh.2014.04.016. View

Lai J, Covinsky K, McCulloch C, Feng S . The Liver Frailty Index Improves Mortality Prediction of the Subjective Clinician Assessment in Patients With Cirrhosis. Am J Gastroenterol. 2017; 113(2):235-242. PMC: 5866923. DOI: 10.1038/ajg.2017.443. View

Dolgin N, Martins P, Movahedi B, Lapane K, Anderson F, Bozorgzadeh A . Functional status predicts postoperative mortality after liver transplantation. Clin Transplant. 2016; 30(11):1403-1410. DOI: 10.1111/ctr.12808. View

10.

Hsu C, Lee Y, Hsia C, Huang Y, Su C, Lin H . Performance status in patients with hepatocellular carcinoma: determinants, prognostic impact, and ability to improve the Barcelona Clinic Liver Cancer system. Hepatology. 2012; 57(1):112-9. DOI: 10.1002/hep.25950. View

11.

Bittermann T, Makar G, Goldberg D . Early post-transplant survival: Interaction of MELD score and hospitalization status. J Hepatol. 2015; 63(3):601-8. PMC: 4543524. DOI: 10.1016/j.jhep.2015.03.034. View

12.

Kulkarni S, Chen H, Josbeno D, Schmotzer A, Hughes C, Humar A . Gait Speed and Grip Strength Are Associated With Dropping Out of the Liver Transplant Waiting List. Transplant Proc. 2019; 51(3):794-797. DOI: 10.1016/j.transproceed.2019.01.030. View

13.

Roman E, Garcia-Galceran C, Torrades T, Herrera S, Marin A, Donate M . Effects of an Exercise Programme on Functional Capacity, Body Composition and Risk of Falls in Patients with Cirrhosis: A Randomized Clinical Trial. PLoS One. 2016; 11(3):e0151652. PMC: 4807034. DOI: 10.1371/journal.pone.0151652. View

14.

Lai J, Segev D, McCulloch C, Covinsky K, Dodge J, Feng S . Physical frailty after liver transplantation. Am J Transplant. 2018; 18(8):1986-1994. PMC: 6066446. DOI: 10.1111/ajt.14675. View

15.

Weismuller T, Negm A, Becker T, Barg-Hock H, Klempnauer J, Manns M . The introduction of MELD-based organ allocation impacts 3-month survival after liver transplantation by influencing pretransplant patient characteristics. Transpl Int. 2009; 22(10):970-8. DOI: 10.1111/j.1432-2277.2009.00915.x. View

16.

Lai J, Feng S, Terrault N, Lizaola B, Hayssen H, Covinsky K . Frailty predicts waitlist mortality in liver transplant candidates. Am J Transplant. 2014; 14(8):1870-9. PMC: 4107151. DOI: 10.1111/ajt.12762. View

17.

Buchard B, Boirie Y, Cassagnes L, Lamblin G, Coilly A, Abergel A . Assessment of Malnutrition, Sarcopenia and Frailty in Patients with Cirrhosis: Which Tools Should We Use in Clinical Practice?. Nutrients. 2020; 12(1). PMC: 7020005. DOI: 10.3390/nu12010186. View

18.

Carey E, Steidley D, Aqel B, Byrne T, Mekeel K, Rakela J . Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010; 16(12):1373-8. DOI: 10.1002/lt.22167. View

19.

Plauth M, Cabre E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J . ESPEN Guidelines on Enteral Nutrition: Liver disease. Clin Nutr. 2006; 25(2):285-94. DOI: 10.1016/j.clnu.2006.01.018. View

20.

Mor V, Laliberte L, Morris J, Wiemann M . The Karnofsky Performance Status Scale. An examination of its reliability and validity in a research setting. Cancer. 1984; 53(9):2002-7. DOI: 10.1002/1097-0142(19840501)53:9<2002::aid-cncr2820530933>3.0.co;2-w. View