Preoperative NLR and INR, and intraoperative cold ischemia time as predictors of short-term mortality risk in paediatric liver transplantation: a LASSO-cox model study

Objectives Liver transplantation (LT) is an effective treatment for end-stage liver disease in children, but precise risk stratification tools for postoperative mortality remain needed.Methods We retrospectively analyzed 383 pediatric LT recipients, categorized into death (n =31) and survival (n =352) groups. Variables were screened via LASSO regression, and independent risk factors were identified using multivariate Cox regression to construct a nomogram. Internal validation employed bootstrap resampling (1,000 iterations). Discrimination and calibration were assessed using Harrell’s C-index, calibration curves, and Brier scores. Predictive performance was compared with Pediatric End-Stage Liver Disease (PELD) and Child-Pugh scores using time-dependent AUC. Decision curve analysis (DCA) evaluated clinical net benefit.Results Multivariate Cox regression identified preoperative neutrophil-to-lymphocyte ratio (H R=1.125, 95%CI:1.058–1.197, p < 0.001), preoperative international normalized ratio (H R=1.728, 95%CI:1.430–2.087, p < 0.001), and cold ischemia time (HR=1.003, 95%CI:1.002–1.005, p < 0.001) as independent risk factors. The nomogram achieved a bootstrap-corrected C-index of 0.707 (95%CI:0.607–0.816). Calibration curves showed excellent agreement at 1, 3, and 12 months postoperatively. Time-dependent AUCs at 1 month (0.944), 3 months (0.874), and 12 months (0.774) significantly outperformed PELD and Child-Pugh scores (all p < 0.05). High-risk patients exhibited significantly inferior long-term survival (p < 0.0001). DCA confirmed positive net benefit.Conclusions This nomogram, incorporating preoperative NLR, INR, and cold ischemia time, effectively predicts short- and medium-term mortality after pediatric LT, outperforming conventional scores and offering a reliable tool for individualized risk assessment.