Background: Cirrhosis is characterized by sarcopenia and malnutrition, leading to progressive functional decline. No studies have objectively measured physical functional decline in cirrhotics awaiting liver transplantation (LT) and its association with wait-list mortality.

Methods: Consecutive adult outpatients (pts) listed for LT with laboratory Model for End-Stage Liver Disease (MELD) ≥12 at a single center underwent functional status assessments at baseline and at every clinic visit using the Short Physical Performance Battery (SPPB; range 0=impaired to 12=robust) consisting of walk speed, timed chair stands, and balance. δSPPB/month(mo) = last minus baseline assessment / time in mos. Competing risks models associated δSPPB/mo with death/delisting for being too sick for LT, treating deceased donor LT (DDLT) as the competing risk (living donor LT pts were censored at LT).

Results: Included were 241 listed LT pts with MELD≥12: median age 59y, 53% HCV, 20% hepatocellular carcinoma. At a median follow-up of 8.4 mos, 12% died/were delisted, 23% had DDLT. Pts who died/were delisted vs. underwent DDLT vs. still waiting differed by median MELD at baseline (17 vs. 16 vs. 14), last visit (17 vs. 18 vs. 15), and δMELD/mo (0.1 vs. 0.2 vs. 0.0) [p<0.01 for each]. In pts who died/were delisted vs. DDLT vs. still waiting, median SPPB was 10 vs. 11 vs. 11 at first (p=0.4) and 8.5 vs. 10 vs. 11 at last visit (p<0.01). 61% vs. 43% vs. 32% experienced decline in SPPB (p=0.02) with a median δSPPB/mo of -0.2 vs. 0.0 vs. 0.0 (p<0.01). In univariable competing risks analysis, δSPPB/mo was associated with a 2.7-fold increased risk of death/delisting (95% CI = 1.5-5.1; p<0.01), which remained significant after adjustment for δMELD/mo and baseline assessment score (hazard ratio = 6.2; 95% CI = 3.0-12.7; p<0.01).

Conclusions: LT candidates experience significant functional decline on the wait-list, despite modest wait-time and low baseline MELD. Decline in physical function as measured by SPPB is associated with an increased risk of death/delisting, independent of MELD score. Exercise-based interventions aimed at maintaining physical function may reduce wait-list mortality.

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