Background and Aims: Frailty is a well-established risk factor for poor outcomes in patients with cirrhosis awaiting liver transplantation (LT), but whether it predicts outcomes among those who have undergone LT is unknown. Approach and Results: Adult LT recipients from 8 US centers (2012–2019) were included. Pre-LT frailty was assessed in the ambulatory setting using the Liver Frailty Index (LFI). “Frail” was defined by an optimal cut point of LFI ≥ 4.5. We used the 75th percentile to define “prolonged” post-LT length of stay (LOS; ≥12 days), intensive care unit (ICU) days (≥4 days), and inpatient days within 90 post-LT days (≥17 days). Of 1166 LT recipients, 21% were frail pre-LT. Cumulative incidence of death at 1 and 5 years was 6% and 16% for frail and 4% and 10% for nonfrail patients (overall log-rank p = 0.02). Pre-LT frailty was associated with an unadjusted 62% increased risk of post-LT mortality (95% CI, 1.08–2.44); after adjustment for body mass index, HCC, donor age, and donation after cardiac death status, the HR was 2.13 (95% CI, 1.39–3.26). Patients who were frail versus nonfrail experienced a higher adjusted odds of prolonged LT LOS (OR, 2.00; 95% CI, 1.47–2.73), ICU stay (OR, 1.56; 95% CI, 1.12–2.14), inpatient days within 90 post-LT days (OR, 1.72; 95% CI, 1.25–2.37), and nonhome discharge (OR, 2.50; 95% CI, 1.58–3.97). Conclusions: Compared with nonfrail patients, frail LT recipients had a higher risk of post-LT death and greater post-LT health care utilization, although overall post-LT survival was acceptable. These data lay the foundation to investigate whether targeting pre-LT frailty will improve post-LT outcomes and reduce resource utilization.
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