*Purpose: Acute on chronic liver failure (ACLF) is a condition associated with high waitlist mortality and graded according to the number of organ system failures present. Functional status, as measured by the Karnofsky performance scale (KPS), is associated with increased mortality in patients with cirrhosis. We investigated the association between KPS score and mortality among patients with different grades of ACLF.

*Methods: We studied the UNOS database, years 2010-2017. KPS was categorized as either low (10-40%) or intermediate/high (50-100%). Patients with ACLF were identified at the time of listing as defined by the EASL-CLIF criteria and categorized as no ACLF, ACLF-1, ACLF-2 and ACLF-3. We used competing risks regression to examine the association between KPS and 90-day waitlist mortality among different grades of ACLF.

*Results: A total of 85,801 patients were studied at listing, of which 66,552 had no ACLF, 9,927 had ACLF-1, 5,341 had ACLF-2 and 3,981 had ACLF-3. Patients with ACLF-3 had the highest proportion of patients with low KPS (87.7%). Competing risks regression adjusted for age, MELD-Na score and etiology of liver disease demonstrated that low KPS score was significantly associated with 90-day waitlist mortality, among those with no ACLF (SHR=1.52, 95% CI 1.36-1.71), ACLF-1 (SHR=1.44, 95% CI 1.25-1.66) and ACLF-2 (SHR=1.23, 95% CI 1.04-1.45), but not for patients with ACLF-3 (SHR=1.19, 95% CI 0.97-1.47). When comparing all groups, low KPS score among patients with no ACLF and ACLF-1 was associated with greater waitlist mortality than candidates with ACLF-3 and intermediate to high KPS score. Patients with ACLF-3 and low KPS had the greatest 90-day waitlist mortality (85%) (figure)

*Conclusions: Patients listed for transplantation with no ACLF or ACLF-1 and low KPS score have greater waitlist mortality than patients with intermediate to high KPS score and any grade of ACLF, including ACLF-3.

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