Frailty is a powerful predictor of outcomes after liver transplantation, but it cannot be used alone to determine transplant candidacy because many frail patients still achieve acceptable survival. This multicenter prospective study introduces the Liver Transplant Comorbidity Index (LTCI), a composite tool designed to better identify patients at higher risk of longer-term post–liver transplant mortality by integrating frailty with other key comorbidities.
Frailty is a powerful predictor of outcomes after liver transplantation, but it cannot be used alone to determine transplant candidacy because many frail patients still achieve acceptable survival. This multicenter prospective study introduces the Liver Transplant Comorbidity Index (LTCI), a composite tool designed to better identify patients at higher risk of longer-term post–liver transplant mortality by integrating frailty with other key comorbidities.
Using data from the Functional Assessment in Liver Transplantation (FrAILT) study across eight transplant centres, the investigators evaluated adults undergoing primary deceased-donor liver transplantation. Frailty was assessed using the Liver Frailty Index, and additional clinical variables were examined to determine their contribution to three-year posttransplant mortality. Through a combination of statistical rigor and clinical pragmatism, the final LTCI incorporated five readily available pretransplant factors: frailty, coronary artery disease, hepatocellular carcinoma, renal dysfunction, and diabetes.
The LTCI effectively stratified patients into low-, moderate-, and high-risk groups with progressively worse posttransplant survival. Importantly, the index remained predictive even after accounting for donor-related factors, demonstrating that recipient comorbidity burden meaningfully influences outcomes beyond traditional transplant risk models.
Clinically, the LTCI provides a balanced framework for transplant decision-making. Rather than excluding patients based on frailty alone, it contextualises frailty alongside other comorbidities, allowing clinicians to more accurately weigh transplant risks and benefits. This tool may help standardise candidate assessment, support shared decision-making, and promote equitable and evidence-based liver transplant selection.
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