title: Functional impairment in older liver transplantation candidates: From the functional assessment in liver transplantation study.
abstract: The emerging epidemic of older patients with cirrhosis has led to a sharp increase in the number of ≥65 year olds considering liver transplantation (LT). However, clinicians lack objective measures to risk stratify older patients. We aimed to determine whether the short physical performance battery (SPPB), a well-validated geriatric measure of physical function, has greater prognostic value in older versus younger LT candidates. Adult outpatients listed for LT with laboratory Model for End-Stage Liver Disease score ≥ 12 underwent physical function testing using the SPPB, consisting of gait speed, chair stands, and balance. Patients were categorized by age ("younger," < 65 years; "older," ≥ 65 years) and SPPB ("impaired," ≤ 9; "robust," > 9). Competing risks models associated age and SPPB with wait-list death/delisting. Of 463 LT candidates, 21% were ≥ 65 years and 18% died or were delisted. Older patients had slower gait (1.1 versus 1.3 m/seconds; P < 0.001), a trend of slower chair stands (12.8 versus 11.8 seconds; P = 0.06), and a smaller proportion able to complete all balance tests (65% versus 78%; P = 0.01); SPPB was lower in older versus younger patients (10 versus 11; P = 0.01). When compared to younger robust patients as a reference group, younger impaired patients (hazard ratio [HR], 1.77; P = 0.03) and older impaired patients (HR, 2.70; P = 0.003) had significantly higher risk of wait-list mortality, but there was no difference in risk for older robust patients (HR 1.38; P = 0.35) [test of equality, P = 0.01]. After adjustment for Model for End-Stage Liver Disease-sodium (MELD-Na) score, only older impaired patients had an increased risk of wait-list mortality compared to younger robust patients (HR, 2.36; P = 0.01; test of equality P = 0.05). In conclusion, functional impairment, as assessed by the SPPB, predicts death/delisting for LT candidates ≥65 years independent of MELD-Na. Further research into activity-based interventions to reduce adverse transplant outcomes in this population is warranted.
authors.affiliation: Divisions of Gastroenterology and Hepatology, University of California, San Francisco, CA.
authors.forename: Connie W
authors.initials: CW
authors.lastname: Wang
authors.affiliation: Geriatrics, Department of Medicine, University of California, San Francisco, CA.
authors.forename: Kenneth E
authors.initials: KE
authors.lastname: Covinsky
authors.affiliation: Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA.
authors.forename: Sandy
authors.initials: S
authors.lastname: Feng
authors.affiliation: Divisions of Gastroenterology and Hepatology, University of California, San Francisco, CA.
authors.forename: Hilary
authors.initials: H
authors.lastname: Hayssen
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
authors.affiliation: Divisions of Gastroenterology and Hepatology, University of California, San Francisco, CA.
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Lai
mesh_terms: D000368:Aged; D005260:Female; D015577:Geriatric Assessment; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011446:Prospective Studies; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists / Q000401:mortality*