Frailty and Sarcopenia as Routine Pre-Transplant Predictors: Moving Beyond MELD-Based Risk Assessments

The MELD-based scoring system is the most important tool to date for liver transplant allocation. It is useful as an index of the severity of the disease, but not a true measure of functional capacity, physiologic reserve or of the wider implications of end-stage liver disease. Frailty and sarcopenia have gained attention as important prognostic markers that provide information beyond traditional laboratory tests. This narrative review examines current evidence on the role of frailty and sarcopenia in liver transplant candidates. Focus is placed on waitlist mortality, post-transplant outcomes, and potential implications for decision-making. Studies evaluating the Liver Frailty Index (LFI), radiologic measures of sarcopenia and associated outcomes in patients with cirrhosis were reviewed. The LFI is a commonly used measurement of frailty. It is linked with increased risk of waitlist mortality even after adjusting for current MELD-based allocation models, ascites and hepatic encephalopathy. Frailty has been demonstrated not to be fixed and even modest gains are associated with reductions in mortality. Liver transplantation should not be precluded only based on frailty, as liver transplant recipients experience a survival benefit across the full spectrum of frailty severity. There is also a strong correlation between sarcopenia, myosteatosis and poor outcomes such as increased waitlist and post-transplant mortality; complications and prolonged hospital stay. Frailty and sarcopenia are closely related and when taken together, they give a better overall picture than either measure alone. Frailty and sarcopenia are complementary predictors of outcomes in liver transplant candidates, addressing important gaps in MELD-based allocation models. Incorporating performance and body composition measures into pre-transplant evaluation may improve prognostic accuracy, help identify patients for prehabilitation and support a better approach to patient assessment and management.