Functional Impairment in Older Liver Transplant Candidates: From the Functional Assessment in Liver Transplantation (FrAILT) Study

摘要

The emerging epidemic of older cirrhotics has led to a sharp increase in the number of ≥65 year olds considering liver transplantation (LT). However, clinicians lack objective measures to risk stratify older patients. We aimed to determine whether the Short Physical Performance Battery (SPPB), a well-validated geriatric measure of physical function, has greater prognostic value in older versus younger LT candidates. Adult outpatients listed for LT with laboratory MELD ≥12 underwent physical function testing using the SPPB, consisting of gait speed, chair stands, and balance. Patients were categorized by age (“younger”= <65 years; “older”= ≥65 years) and SPPB (“impaired”= ≤9; “robust”= >9). Competing risks models associated age and SPPB with wait-list death/delisting. Of 463 LT candidates, 21% were ≥65 years; 18% died/delisted. Older patients had slower gait (1.1 vs.1.3m/sec; p<0.001), a trend of slower chair stands (12.8 vs.11.8sec; p=0.06), and a smaller proportion able to complete all balance tests (65 vs.78%; p=0.01); SPPB was lower in older vs. younger patients (10 vs.11; p=0.01). When compared to younger robust patients as a reference group, younger impaired patients (HR 1.77; p=0.03) and older impaired patients (HR 2.70; p=0.003) had significantly higher risk of wait-list mortality, but there was no difference in risk for older robust patients (HR 1.38; p=0.35) [test of equality p=0.01]. After adjustment for MELD-Na, only older impaired patients had an increased risk of wait-list mortality compared to younger robust patients (HR 2.36; p=0.01) [test of equality p=0.05]. In conclusion, functional impairment, as assessed by the SPPB, predicts death/delisting for LT candidates ≥ 65 years independent of MELD-Na. Further research into activity-based interventions to reduce adverse transplant outcomes in this population is warranted.