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Patients with end-stage renal disease (ESRD) have impaired functional status compared with the general population. We sought to explore the association between Karnofsky Performance Status (KPS) and death/delisting from the kidney transplantation waitlist and whether this association differed by age. Patients listed for single-organ kidney transplantation in the United Network for Organ Sharing/Organ Procurement and Transplantation Network from January 1, 2015, to January 1, 2018, were included. We performed competing-risk regression analyses to determine the association between KPS ("Severely impaired", "Moderately impaired", "Non-impaired") and death/delisting, with deceased-donor kidney transplantation as a competing risk. We tested for interactions between age and KPS on death/delisting. Of the 89,819 patients analyzed, 39% were impaired (KPS

This national survey sought to determine the practices and policies pertaining to opioid and opioid substitution therapy (OST) use in the selection of liver transplant (LT) candidates. Of 114 centers, 61 (53.5%) responded to the survey, representing 49.2% of the LT volume in 2016. Only two programs considered chronic opioid (1 [1.6%]) or OST use (1 [1.6%]) absolute contraindications to transplant, while 63.9% and 37.7% considered either one a relative contraindication, respectively. The majority of programs did not have a written policy regarding chronic opioid use (73.8%) or OST use (78.7%) in LT candidates. Nearly half (45.9%) of centers agreed that there should be a national consensus policy addressing opioid and OST use. The majority of responding LT centers did not consider opioid or OST use in LT candidates to be absolute contraindications to LT, but there was significant variability in center practices. These surveys also demonstrated a lack of written policies in the assessment of the candidacy of such patients. The results of our survey identify an opportunity to develop a national consensus statement regarding opioid and OST use in LT candidates to bring greater uniformity and equity into the selection of LT candidates.

United Network for Organ Sharing (UNOS) policies allow for ABO-nonidentical liver transplantation (LT) in candidates with Model for End-Stage Liver Disease (MELD) scores greater than 30. Previous studies showed ABO-nonidentical LT resulted in an 18% and 55% net gain in livers for B and AB candidates. These results suggested that the current liver ABO allocation policies may need refinement. There are, however, strong associations between ABO blood groups and race/ethnicity. We hypothesized that race/ethnicity is associated with ABO-nonidentical LT and that this is primarily influenced by recipient ABO status. We examined non-status 1 adult candidates registered between July 1, 2013, and December 31, 2015. There were 27 835 candidates (70% non-Hispanic White, 15% Hispanic, 9% Black, 4% Asian, 1% Other/Multiracial). A total of 11 369 underwent deceased donor LT: 93% ABO identical, 6% ABO compatible, and 1% ABO incompatible. Black and Asian race/ethnicity were associated with increased likelihoods of ABO-nonidentical LT. Adjustment for disease etiology, listing MELD, transplant center volume, and UNOS region did not alter this association. Stepwise inclusion of recipient ABO status did eliminate this significant association of race/ethnicity with ABO-nonidentical LT. Blacks and Asians may be advantaged by ABO-nonidentical LT, and we suspect that changes to the existing policies may disproportionately impact these groups.

Introduction: Cognitive impairment (CI) among liver transplant (LT) candidates is associated with increased risk of waitlist mortality and inferior outcomes. While formal neurocognitive evaluation is the gold standard for CI diagnosis, the Montreal Cognitive Assessment (MoCA) is often used for first‐line cognitive screening. However, MoCA requires specialized training and may be too lengthy for a busy evaluation appointment. An alternate approach may be the Quick Dementia Rating System (QDRS), which is patient‐ and informant‐based and can be administered quickly. We compared potential LT candidates identified by MoCA and QDRS as potentially benefiting from further formal cognitive evaluation. Methods: We identified 46 potential LT candidates enrolled at a single center of a prospective, observational cohort study who were administered MoCA and QDRS during transplant evaluation (12/2021–12/2022). Scores were dichotomized as (1) normal versus abnormal and (2) normal/mild impairment versus more‐than‐mild impairment. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of QDRS compared to MoCA. Results: By MoCA, this population had a prevalence of 48% normal cognition, 48% mild, 4% moderate, and 0% severe impairment. This was categorized as 96% normal/mild and 4% more‐than‐mild impairment. When comparing to MoCA cognitive screening, QDRS had a sensitivity of 61%, specificity of 56%, NPV of 56%, and PPV of 61%. When identifying more‐than‐mild impairment, QDRS had a sensitivity of 100%, specificity of 73%, NPV of 100%, and PPV of 10%. Conclusion: The high sensitivity and NPV of QDRS in identifying more‐than‐mild impairment suggests it could identify potential LT candidates who would benefit from further formal cognitive evaluation. The ability to administer QDRS quickly and remotely makes it a pragmatic option for pre‐transplant screening. [ABSTRACT FROM AUTHOR]

Liver transplant (LT) recipients have a high burden of cognitive impairment risk factors identified in other populations, yet little work has explored cognition in the United States LT population. We characterized prevalence of cognitive impairment (CI) in LT recipients pre‐LT and ≥3 months post‐LT. Adult LT recipients with cirrhosis but without active pre‐LT hepatic encephalopathy (HE) were screened for CI using the Montreal Cognitive Assessment (MoCA) for CI (MoCA <24) both pre‐LT and ≥3 months post‐LT. The association between cognitive performance and recipient characteristics was assessed using logistic regression. Of 107 LT recipients, 36% had pre‐LT CI and 27% had post‐LT CI [median (Q1–Q3) MoCA 26 (23–28)]. Each 1‐point increase in pre‐LT MoCA was associated with 26% lower odds of post‐LT cognitive impairment (aOR.74, 95% CI.63–.87, p <.001), after adjusting for recipient age, history of HE, and time since LT. In this study of cirrhosis recipients without active pre‐LT HE, cognitive impairment was prevalent before LT and remained prevalent ≥3 months after LT (27%), long after effects of portal hypertension on cognition would be expected to have resolved. Our data expose an urgent need for more comprehensive neurologic examination of LT recipients to better identify, characterize, and address predictors of post‐LT cognitive impairment. [ABSTRACT FROM AUTHOR]

Background: Older adults have higher healthcare utilization after liver transplantation (LT), yet objective risk stratification tools in this population are lacking. We evaluated the Liver Frailty Index (LFI) as one potential tool. Methods: Ambulatory LT candidates ≥65 years without hepatocellular carcinoma (HCC) who underwent LT from 1/2012 to 6/2022 at 8 U.S. centers were included. Estimates of the difference in median using quantile regression were used to assess the adjusted association between LFI and hospitalized days within 90 days post‐LT. Results: Of 131 LT recipients, median (interquartile range [IQR]) (1st‐3rd quartiles) age was 68 years (66‐70); median pre‐LT MELD‐Na was 19 (15‐24). Median LFI was 4.1 (3.6‐4.7); 27% were frail (LFI≥4.5). Median hospitalized days within 90 days post‐LT was 11 (7‐20). Compared with non‐frail patients, frail patients were hospitalized for a median of 5 days longer post‐LT (95% CI.30‐9.7, p =.04). Each.5 unit increase in pre‐LT LFI was associated with an increase of 1.16 days (95%CI.42‐2.69, p =.02) in hospitalized days post‐LT. Conclusion: Among older adults undergoing LT, frailty was associated with more hospitalized days within 90 days after LT. The LFI can identify older adults who might benefit from pre‐LT or early post‐LT programs which may reduce post‐LT healthcare utilization, such as early rehabilitation or post‐hospital discharge programs. [ABSTRACT FROM AUTHOR]

Background: Patients with obesity have inferior outcomes after general surgery procedures, but studies evaluating post‐liver transplant (LT) outcomes have been limited by small sample sizes or lack of granularity of outcomes. We evaluated the relationship between obesity and post‐LT outcomes, including those observed in other populations to be obesity‐related. Methods: Included were 1357 LT recipients prospectively enrolled in the ambulatory pre‐LT setting at 8 U.S. centers. Recipient were categorized by body mass index (BMI, kg/m2): non‐obese (BMI < 30), class 1 obesity (BMI 30–<35), and classes 2–3 obesity (BMI ≥ 35). Post‐transplant complications were compared by BMI using Chi‐square and rank‐sum testing, logistic regression, Kaplan‐Meier curves, and Cox regression. Results: Classes 2–3 obesity was associated with higher adjusted odds than non‐obesity of venous thrombosis [adjusted odds ratio (aOR) 2.06, 95% CI 1.01–4.23, p =.047] and wound dehiscence (aOR 2.45, 95% CI 1.19–5.06, p =.02). Compared with non‐obese recipients, post‐LT hospital stay was significantly longer for recipients with classes 2–3 obesity [p =.01; median (Q1–Q3) 9 (6–14) vs. 8 (6–12) days) or class 1 obesity [p =.002; 9 (6–14) vs. 8 (6–11) days]. Likelihood of ICU readmission, infection, discharge to a non‐home facility, rejection, 30‐day readmission, and 1‐year readmission were similar across BMI categories (all p >.05). Conclusion: Compared to non‐obese recipients, obese recipients had similar post‐LT survival but longer hospital stay and higher likelihood of wound dehiscence and venous thrombosis. These findings underscore that obesity alone should not preclude LT, but recipients with obesity should be monitored for obesity‐related complications such as wound dehiscence and venous thrombosis. [ABSTRACT FROM AUTHOR]

Background & aims: Liver transplantation for alcohol‐related liver disease (ARLD) has increased. We examined temporal trends in ARLD listing practices by neighborhood deprivation and evaluated the impact of neighborhood deprivation on waitlist mortality. Methods: We included all adults > 18 years listed 2008‐2019 in the UNOS registry. Our primary exposure was the neighborhood socioeconomic deprivation index based on patients' listing zip codes. We determined temporal trends in an ARLD listing diagnosis. We modeled ARLD listing diagnosis using logistic regression and waitlist mortality using Cox proportional hazards models. Results: The waitlist contained an increasing proportion of patients listed with ARLD over the study period; however, this rate increased the least for patients from the most deprived tertile (p <.001). Patients from the most deprived tertile were the least likely to be listed with ARLD (OR:.97, 95CI:.95‐.98). In our adjusted model, patients from the most deprived tertile had an increased hazard of waitlist mortality (OR: 1.10, 95CI: 1.06‐1.14). Conclusion: Neighborhood deprivation was associated with a decreased likelihood of being listed with ARLD, suggesting that transplant for ARLD is inequitably available. The increased mortality associated with neighborhood deprivation demands future work to uncover the underlying reasons for this disparity. [ABSTRACT FROM AUTHOR]

Background: To implement Enhanced Recovery After Surgery (ERAS) protocols for liver transplant (LT) candidates, it is essential to identify tools that can help risk stratify patients by their risk of early adverse post‐LT outcomes. Objective: We aimed to identify pre‐LT tools that assess functional capacity, frailty, and muscle mass that can best risk stratify patients by their risk of adverse post‐LT outcomes. Methods: We first conducted a systematic review following PRISMA guidelines, expert panel review and recommendations using the GRADE approach (PROSPERO ID CRD42021237434). After confirming there are no studies evaluating assessment modalities for ERAS protocols for LT recipients specifically, the approach of the review focused on pre‐LT modalities that identify LT recipients at higher risk of worse early post‐LT outcomes (≤90 days), considering that this is particularly pertinent when evaluating candidates for ERAS. Results: Twenty‐two studies were included in the review, encompassing three different types of pre‐LT modalities: evaluation of physical function (including frailty and general physical scores like the Karnofsky Performance Status (KPS), assessment of cardiopulmonary capacity, and estimation of muscle mass and composition. The majority of studies evaluated frailty assessment and muscle mass. Most studies, except for liver frailty index (LFI), were retrospective and single‐center. All assessment modalities could identify, in different grade, LT recipients with higher risk of early post‐LT mortality, length of stay or postoperative complications. Conclusions: We identified four pre‐LT assessment tools that could be used to identify patients who are suitable for ERAS protocols: (1) KPS (quality of evidence moderate, grade of recommendation strong); (2) LFI (quality of evidence moderate, grade of recommendation strong); (3) abdominal muscle mass by CT (quality of evidence moderate, grade of recommendation strong); and (4) cardiopulmonary exercise testing (CPET) (quality of evidence moderate, grade of recommendation weak). We recommend that selection of the appropriate tool depends on the specific clinical setting and available resources to administer the tool, and that use of a tool be incorporated into the routine preoperative assessment when considering implementation of ERAS protocols for LT. [ABSTRACT FROM AUTHOR]