The Liver Frailty Index (LFI), composed of 3 performance‐based tests (grip strength, chair stands, and balance), is a tool specifically developed in patients with cirrhosis to objectively measure physical function, a critical determinant of health outcomes. We aimed to (1) determine the range of LFI scores in adults with chronic liver disease but without cirrhosis, (2) determine the range of LFI scores in adults without known liver disease, and (3) evaluate reproducibility of the LFI in adults with cirrhosis listed for liver transplantation. Intraclass correlation coefficient (ICC) assessed interrater reliability of the LFI. Included were 91 adults with chronic liver disease, 109 adults without known liver disease, and 166 adults with cirrhosis with median Model for End‐Stage Liver Disease–sodium of 16. Median (interquartile range) LFI was 3.6 (3.1‐4.1) in adults with cirrhosis, 3.1 (2.5‐3.7) in adults with chronic liver disease but not cirrhosis, and 2.7 (2.2‐3.2) in adults without liver disease (P < 0.001). Using established LFI cutoffs for robust, prefrail, and frail categories, adults with cirrhosis or chronic liver disease were less likely to be robust (29% versus 53% versus 77%) and more likely to be prefrail (57% versus 42% versus 22%) or frail (14% versus 5% versus 1%) when compared with adults without liver disease (P < 0.001). The LFI had excellent reliability with ICC of 0.93 (95% confidence interval, 0.91‐0.95). In conclusion, the LFI has external validity in noncirrhotic populations and is highly reproducible among different raters. This objective assessment tool can be implemented in outpatient clinical practice or research to operationalize the concept of physical frailty.

Frailty, a state of decreased physiological reserve, has been associated with dysregulation of the immune system. We hypothesized that frailty is associated with differential rates of acute cellular rejection (ACR) in liver transplantation (LT) recipients. Our study included LT recipients from 2014 to 2016 who had a pre‐LT frailty assessment using the liver frailty index (LFI). Frailty was defined as an LFI ≥4.5. ACR at 3 months was ascertained from pathology reports, and immunosuppression regimens were collected from chart review. There were 241 LT recipients who were included: 46 (19%) were classified as frail before LT. Median tacrolimus trough levels, mycophenolate doses, and corticosteroid doses at discharge and 3 months were similar between frail and nonfrail patients. Within 3 months after LT, 7 (15%) frail patients versus 10 (5%) nonfrail patients experienced ACR (P = 0.02). In the univariate analysis, frailty was associated with a higher odds of ACR at 3 months (OR, 3.3; 95% confidence interval, 1.2‐9.3; P = 0.02). Bivariate analyses were conducted with covariates that were associated with ACR in the univariate analysis or that were previously associated with either frailty (age and female sex) or ACR (Model for End‐Stage Liver Disease score and ascites), as well as relevant immunosuppression variables. In the bivariate analyses, frailty remained significantly associated with ACR at 3 months with an odds ratio relatively similar to the unadjusted value. In conclusion, frailty is associated with an increased rate of ACR within 3 months, despite similar immunosuppression regimens, suggesting that frailty should be considered in immediate post‐LT management.

Background: Patients with end-stage liver disease (ESLD) awaiting liver transplantation (LT) are seriously ill and experience fluctuating periods of clinical decompensation. Discussion of a patient's advance care planning (ACP) wishes early in their dynamic disease course is critical to providing value-aligned care while awaiting LT. We aimed to evaluate current ACP documentation and assess readiness to engage in ACP in this population. Methods:We conducted a retrospective study of adults undergoing LT evaluation from 1/17-6/17 and assessed characteristics associated with documentation using logistic regression. We then administered a survey to LT candidates from 3/18-5/18 to determine self-reported readiness to engage in ACP (range 1=not at all ready to 5=very ready).Results: Among 170 LT candidates, median [interquartile range (IQR)] age was 58 (53-65), 65% were men, MELDNa was 15 (11-21), and Child Pugh A/B/C were 33/38/29%. Nine percent reported completing ACP prior to LT evaluation, but 0% had legal ACP forms or end-of-life wishes documented in the medical record. A durable power of attorney (DPOA) was discussed with 10%. In univariable analysis, white race (OR 4.16, p=0.03) and female sex (OR 3.06, p=0.04) were associated with ACP documentation, but Child Pugh score and MELDNa were not. Of the 41 Terms of use and reuse: academic research for non-commercial purposes, see here for full terms. https://www.springer.com/aamterms-v1

In LT candidates, frailty is associated with cardiac structural and functional changes, independent of known risk factors. Our study provides evidence to support that measures of frailty in cirrhotic patients encompass abnormalities of the cardiovascular system and may inform assessments of cardiovascular reserve in this population.

The World Health Organization defines malnutrition as a term referring to deficiencies, excesses, or imbalances in a person’s intake or energy and/or nutrients. Malnutrition is a nearly universal complication of end-stage liver disease, with a prevalence of up to 90%. Given their hepatic synthetic dysfunction, patients with cirrhosis are at a particularly high risk for protein-calorie depletion, which has been reported in over half of patients with cirrhosis and worsens with disease severity. Undernutrition is a potent predictor of adverse outcomes in cirrhotic patients, including lower survival rates, hepatic decompensation, longer length of days in the hospital and intensive care unit (ICU), increased number of infection episodes, and higher resource utilization. On the other hand, excess energy intake, or overnutrition, is increasingly being recognized as an important determinant of long-term outcomes in this population, particularly those with nonalcoholic steatohepatitis. Nearly one quarter of patients with cirrhosis are overnourished and up to 72% show excessive daily intake of energy and protein. In this review, we will consider the full spectrum of malnutrition in patients with end-stage liver disease and highlight key areas in need of further investigation. This review contains 4 figures, 4 tables, and 54 references. Key Words: frailty, inflammation, nocturnal feeding, nutritional assessment, nutritional risk, nutritional screening, protein-energy malnutrition, sarcopenia