Higher Medical Urgency Is Associated With Greater Psychosocial Risk Tolerance in Liver Transplant Listing and Selection

BACKGROUND: The Model for End-Stage Liver Disease (MELD) score guides liver transplant (LT) allocation, but transplant programs also evaluate psychosocial risks that may affect outcomes such as graft survival, adherence, and follow-up. How medical urgency influences consideration of these risks remains unclear. METHODS: We conducted a retrospective analysis of 2959 adults listed for LT at a large academic center (2012-2023). Using a validated large language model-based techniques, we extracted 23 predefined psychosocial factors from clinical documentation. We compared the prevalence of these factors across MELD categories and assessed associations with successful transplantation. RESULTS: Among listed patients, 10 psychosocial factors increased significantly with higher MELD scores. Low transplant knowledge rose from 3.1% (MELD <15) to 13.3% (MELD >35; adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.22-1.51), history of nonadherence from 7.8% to 22.2% (aOR, 1.25; 95% CI, 1.16-1.35), and past trauma from 5.4% to 12.2% (aOR, 1.19; 95% CI, 1.09-1.30). Among LT recipients, 11 factors showed similar trends, including low transplant knowledge (1.8%-11.1%; aOR, 1.43; 95% CI, 1.23-1.68), nonadherence (5.2%-22.2%; aOR, 1.37; 95% CI, 1.23-1.53), and past trauma (5.2%-13.9%; aOR, 1.22; 95% CI, 1.08-1.37). Adjusting for demographics minimally changed results. CONCLUSIONS: Transplant teams appear to tolerate greater psychosocial risk as medical urgency increases. This suggests psychosocial criteria are applied more flexibly at higher MELD scores. Standardized frameworks that explicitly incorporate medical urgency may improve equity and transparency in transplant decision-making.