La Fe Health Research Institute and CIBEREHD lead a multicentre study that reveals how time on the waiting list affects the impact of frailty in liver transplant candidates.

The researchers in this study recommend that liver transplant teams consider physical frailty as a vital sign, because of its ability to predict complications and post-transplant hospital stay

Physical frailty is a prevalent condition in patients with cirrhosis and is the clinical manifestation of muscle atrophy, malnutrition and functional impairment. A new study published in the journal JHEP Reports by Elsevier and in which the La Fe Health Research Institute (IIS La Fe) participated, along with 4 other Spanish centres (most of them belonging to CIBEREHD), has shown that, in the context of liver transplantation with short waiting times, frailty has no impact on pre-transplant mortality or on the risk of leaving the list due to being too ill for transplantation. In contrast, frailty does impact post-transplant healthcare resource utilisation.

"Solid data based on North American studies associate physical frailty with adverse outcomes both before and after liver transplantation, but to date, evidence in transplant settings outside the United States has been scarce," explains Dr Marina Berenguer, professor at the University of Valencia and leader of the Hepatology, Hepatobiliopancreatic Surgery and Transplantation group at IIS-La Fe and CIBER de Enfermedades Hepáticas y Digestivas (CIBEREHD).

Dr Lorena Puchades, first author and study leader, explains that the main purpose of the study was to externally validate the Hepatic Fragility Index, a continuous index based on three simple physical tests: grip strength measured with a dynamometer, the time it takes a patient to stand up and sit down five times from a chair, and balance.


The researchers recruited outpatients with cirrhosis, included in the liver transplant waiting list, in five Spanish hospitals between 2018 and 2020. Of the 212 patients included in the study, 21% were categorised as frail, according to previously established cut-off points on the Frailty Liver Index.

Although the results obtained did not allow validation of the usefulness of this index for predicting unfavourable outcomes prior to liver transplantation, probably due to the short waiting list period (only 78 days) and the low rate of deaths and exits due to illness (only 5 patients) compared to US studies, a significant difference with "non-frail" transplant candidates was observed. In this regard, "frail" patients had significantly longer hospital stays (9 vs 13 days) and significantly higher complication rates in the first month post-transplant (55% vs 100%).

The authors emphasise that this study lays the groundwork for future research to assess the benefits of preparation and rehabilitation strategies in the context of short waiting times for liver transplantation.

Article Reference:
WAITING TIME DICTATES IMPACT OF FRAILTY: A SPANISH MULTICENTRE PROSPECTIVE STUDY. Puchades, L., Herreras, J., Ibañez, A., Reyes, E., Crespo, G., Rodríguez-Perálvarez, M., Cortés, L., Serrano, T., Fernández-Yunquera, A., Montalvá, E., Berenguer, M.
JHEP Reports. 2023 Jul 11. DOI:

The authors emphasise that this study lays the groundwork for future research to evaluate the benefits of strategies focused on preparedness and rehabilitation in short waiting time liver transplantation settings