*Purpose: Patients with decompensated cirrhosis awaiting liver transplant (LT) exhibit a spectrum of neurocognitive disorders, largely attributed to hepatic encephalopathy (HE) and considered reversible after transplant. Patients with cirrhosis also have risk factors for non-HE causes of cognitive impairment that may persist after LT. We aimed to characterize cognitive impairment ≥ 6 months after LT.

*Methods: We enrolled ambulatory cirrhosis adults awaiting LT. Cognition was assessed ≥ 6 mos post-LT via Brain Health Assessment (BHA): a validated 10-min tablet battery measuring global and domain-specific cognitive functions; performance was reported in z-scores (standard deviations away from demographically-adjusted mean performance in healthy subjects); “cognitive impairment”=z-score ≤-2. Frailty was assessed via Liver Frailty Index (LFI); continuous variable; every 0.1 unit increase=increased frailty. Covariates were collected at pre-LT clinic visit closest to LT (HTN, DM, cirrhosis etiology, MELDNa, HE history, LFI), or date of BHA assessment (age, education, depression severity [Patient Health Questionnaire-9], immunosuppression, time since LT). Descriptive statistics and linear regression were performed.

*Results: 67% of LT recipients had cognitive impairment at a median of 22 mos post-LT. In contrast, prevalence of cognitive impairment in 60 yo in the general population is 6%. Post-LT cognitive impairment was significantly associated with pre-LT frailty. Other classical predictors of dementia like hypertension may also be associated. Our data raise questions about whether pre-LT cognitive dysfunction truly represents HE and whether peri- or post-LT factors lead to cognitive impairment in LT recipients. Assessments of pre-LT frailty may help to identify those at greatest risk for post-LT cognitive dysfunction.

*Conclusions: Cognitive impairment was highly prevalent (67%) in LT recipients a median of 22 months post-LT. In contrast, prevalence of cognitive impairment in 60-year-olds from the general population is 6%; prevalence in 80-year-olds is 25%. Post-LT cognitive impairment was significantly associated with pre-LT frailty, with every 1 unit increase in frailty independently associated with a 1.2 unit decrease in standardized cognitive performance score. Other classical predictors of dementia like hypertension may also be associated. Our data raise questions about whether pre-LT cognitive dysfunction truly represents HE and whether there are peri- or post-LT factors that lead to cognitive impairment in LT recipients. Assessments of pre-LT frailty may help to identify those at greatest risk for post-LT cognitive dysfunction.

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