*Purpose: To understand the importance of pre-transplant nutritional status in optimizing liver transplant outcomes.

*Methods: The prognostic nutritional index (PNI) is a  serum  marker of nutrition and inflammation.  We hypothesized pre-transplant PNI  would  predict short-term post-LT outcomes in deceased donor liver transplant (DDLT) patients. 451  patients underwent primary  DDLT between 2013-2018  at our center.  Re-transplants, multi-organ transplants  and living  donor liver transplants were excluded.  Pre-transplant  PNI = (10)*[albumin (g/dL)] + (0.005)*[Total Lymphocyte Count (/µL)].  PNI was  analyzed as both a continuous and categorical variable. ROC curves yielded an optimal PNI cutoff of 35 to  compare short-term outcomes between PNI≥35 and PNI<35 cohorts.  Risk factors for patient death within 1-year were analyzed  using Cox regression models and adjusted by recipient factors at LT. 

*Results: Multivariable  analysis  associated PNI with 1-year survival as a continuous variable  (HR=0.94, 95% CI=0.90-0.98; p=0.007).  Of 451 patients, 215 (47.7%) had PNI<35.  MELD score at time of transplant was higher in PNI<35 (22 vs. 19; p=0.028). Recipient age, gender, BMI, donor age, rates of diabetes mellitus and donors after cardiac death were equivocal. PNI<35 demonstrated lower 1-year survival (89.6% vs. 95.2%; p=0.026,  Figure A). After risk adjustment, PNI<35 showed higher risk of 6-month (HR=2.44; p=0.047) and 1-year death (HR=2.47; p=0.018).  Multivariable analysis revealed PNI<35  at LT  (HR=2.37; p=0.023) was an independent risk factor for patient death within 1 year (Figure B).

*Conclusions: Lower pre-transplant PNI portended worse short-term survival  in DDLT patients. PNI may be useful in evaluating pre-transplant nutritional status and optimizing LT outcomes.

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