Frailty Assessment to Improve Evaluation of Cirrhotic Patients on the Liver Transplant Waiting List

The MELD score is the main tool used worldwide to prioritize patients with cirrhosis for liver transplantation, as it predicts short-term mortality based on laboratory markers of liver and kidney dysfunction. However, MELD focuses almost exclusively on liver synthetic and excretory failure and does not capture other critical manifestations of advanced cirrhosis. Important contributors to morbidity and mortality—such as portal hypertension, malnutrition, sarcopenia, and overall physical decline—are therefore overlooked. Frailty has emerged as a powerful clinical marker reflecting the systemic and extrahepatic consequences of cirrhosis. Numerous studies have shown that frailty strongly predicts complications including infections, hospitalizations, hepatic encephalopathy, acute-on-chronic liver failure, and death among patients on the transplant waiting list. Importantly, frailty provides prognostic information that is independent of and complementary to the MELD score. This added value is particularly relevant in patients with lower MELD scores, in whom disease severity and vulnerability may be underestimated. Incorporating frailty assessment into transplant evaluation could improve risk stratification and help identify patients at higher risk of waitlist mortality. Prognostic models combining MELD with frailty measures—and potentially comorbidity indices—appear to offer superior predictive accuracy compared with MELD alone. Frailty assessment may also guide selection of patients for prehabilitation programs and allow monitoring of functional improvement over time. Simple, objective, performance-based tools such as the Five-Times Sit-to-Stand Test are especially suitable for routine clinical practice. Overall, integrating frailty into liver transplant evaluation may enhance patient selection and improve transplant outcomes.