Functional impairment in older liver transplantation candidates: From the functional assessment in liver transplantation study

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. Liver Transpl 21:1465‐1470, 2015 . © 2015 AASLD.