Background: Frailty is a critical determinant of waitlist outcomes. The most commonly-used test to assess frailty in liver transplant (LT) candidates is the “eyeball test”, which is limited by its subjectivity. We aimed to compare the objective Liver Frailty Index, which we developed using 3 performance-based tests (grip, chair stands, balance), with a subjective assessment by hepatologists.

Methods: Outpatient LT candidates w/o HCC underwent 2 frailty assessments:

1) Liver Frailty Index: (-0.3*gender-adjusted grip)+(-2.5*chair stands)+(-0.04*balance)+6, vs.

2) Eyeball test [0(robust)-5(frail)], assessed by a hepatologist (n=9; range 3-21y in practice).

Spearman's correlation and linear regression quantified associations b/n the Liver Frailty Index, the eyeball test, and clinical characteristics. Cox regression assessed associations with waitlist mortality (death/delisting for sickness). Discriminative ability for waitlist mortality was assessed with Concordance(C) statistics and compared with bootstrapping.

Results: Of 543 LT candidates: median age was 58y, MELDNa 18, and Child-Pugh (CPT) 8. Median(interquartile range) Liver Frailty Index was 3.8(3.4-4.3) and eyeball test score was 3(1-3).

Correlation b/n the Liver Frailty Index and the eyeball test was modest (rho=0.38; p<0.01) with high variability by provider (rho=0.26-0.70) independent of hepatologists' # of clinical practice years (rho= -0.12; p=0.8).

At a median followup of 11 months, 106 (20%) died/were delisted. Both the Liver Frailty Index (HR 3.0, 95% CI 2.3-3.8) and the eyeball test (HR 1.9, 95%CI 1.6-2.2) were associated with waitlist mortality [p<0.01].

C-statistics for the Liver Frailty Index were higher than, but not statistically significantly different from, the eyeball test (0.72 vs. 0.68; p=0.33). The addition of the Liver Frailty Index to the eyeball test significantly improved waitlist mortality prediction over the eyeball test alone (0.74 vs. 0.68; p<0.01).

Conclusion: The eyeball test can predict waitlist mortality in LT candidates, but is subjective and variable by hepatologist. The Liver Frailty Index was estimated to have slightly better predictive ability than the eyeball test, but the combination of the two assessments demonstrated even better mortality risk prediction than the eyeball test alone. Our data strongly support the incorporation of the objective Liver Frailty Index to anchor our eyeball test to enhance decision-making in LT.

CITATION INFORMATION: Lai J, Covinsky K, McCulloch C, Feng S. The Objective Liver Frailty Index Significantly Improves the Clinician “Eyeball Test” to Predict Mortality in Liver Transplant Candidates. Am J Transplant. 2017;17 (suppl 3).

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