Frailty in liver transplantation: An expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice

Abstract

Frailty has emerged as a powerful predictor of outcomes in patients with cirrhosis and has inevitably made its way into decision making within liver transplantation. In an effort to harmonize integration of the concept of frailty among transplant centers, the AST and ASTS supported the efforts of our working group to develop this statement from experts in the field. Frailty is a multidimensional construct that represents the end-manifestation of derangements of multiple physiologic systems leading to decreased physiologic reserve and increased vulnerability to health stressors. In hepatology/liver transplantation, investigation of frailty has largely focused on physical frailty, which subsumes the concepts of functional performance, functional capacity, and disability. There was consensus that every liver transplant candidate should be assessed at baseline and longitudinally using a standardized frailty tool, which should guide the intensity and type of nutritional and physical therapy in individual liver transplant candidates. The working group agreed that frailty should not be used as the sole criterion for delisting a patient for liver transplantation, but rather should be considered one of many criteria when evaluating transplant candidacy and suitability. A road map to advance frailty in the clinical and research settings of liver transplantation is presented here.

Keywords: clinical research/practice; guidelines; liver transplantation/hepatology; nutrition; recipient selection.

FIGURE 1

Liver-related and non-liver-related factors that contribute to the development of physical frailty in patients with cirrhosis

FIGURE 2

A conceptual model of some of the patient components that clinicians incorporate into their global assessment of a patient’s transplant candidacy and the tools that they use to inform this holistic assessment. An objective frailty tool kit should be used to inform clinicians’ assessments of muscle wasting, under-nutrition, and physical inactivity—which, together, form the major components of physical frailty—to improve objectivity and accuracy of the clinician’s global assessment of transplant candidacy for the purposes of transplant decision-making (adapted from Lai JC, AJG 2017)

FIGURE 3

Algorithm to tailor prehabilitation recommendations based on frailty assessment