*Purpose: The incidence of acute cellular rejection (ACR) following liver transplantation (LT) ranges from 20-40%. Development of ACR is associated with increased risk of graft failure, all-course mortality, and graft failure-related death. Risk factors for ACR include age of donor, prolonged cold ischemia time, and blood concentrations of immunosuppression. There is limited knowledge on whether functional status prior to LT is a risk factor for ACR. By using the Karnofsky Performance Score (KPS), we aim to assess if functional status predicted the development of ACR up to 1 year after LT.

*Methods: We conducted an observational cohort study of patients undergoing LT at the Cleveland Clinic Florida. All patients who underwent LT from 7/11/2013 to 4/29/2017 were included. Functional status was assessed by the KPS that is calculated for all patients prior to undergoing LT. The diagnosis of ACR was made either histologically after review of liver biopsy or clinically with laboratory derangements that improved with adjustment of immunosuppression.

*Results: A total of 124 liver transplants and 26 combined liver kidney transplants were performed. Twelve patients died within 12 months of LT from reasons not related to ACR. All patients received immunosuppression induction with mycophenolate mofetil and solumedrol. The majority (96.3%) of patients received tacrolimus based immunosuppression. Thirty-two (23.2%) patients developed ACR an average of 95 days post LT. The median tacrolimus level at the time of rejection was 3.9 ng/mL (2.9-5.8). Univariate analysis demonstrated that KPS of 10-30 (OR 1.15; 95% CI 0.32-4.18; p=0.83), 40-70 (OR 1.69; 95% CI 0.5-5.67; p=0.40) and 80-100 (OR 1) did not predict development of ACR. Additionally cold ischemia time, nutritional status, and age at time of LT did not significantly influence development of ACR. Multivariate analysis demonstrated that patients transplanted for cirrhosis secondary to HCV (OR 0.31; 95% CI: 0.11-0.88; p=0.03) and those who underwent a simultaneous liver kidney transplant (OR: 0.21;95% CI: 0.05-0.96; p=0.04) were less likely to develop ACR.

*Conclusions: In our cohort, functional status prior to LT did not predict the development of ACR. Functional status is variable in the pre-transplant population and has not been evaluated as a risk-factor for the development of ACR. KPS has been studied as a predictor of mortality in patients awaiting LT and more recently in its role as a predictor of 3 month mortality in cirrhosis patients after hospitalization. Though we hypothesized that patients who were deconditioned prior to LT would have a lower incidence of ACR, we did not observe this when using KPS as an indicator for functional status.

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