Longitudinal Assessment of Performance Status in US Liver Transplantation: National Trends and Survival Implications

Background. The effectiveness of mitigating performance status decline on the liver transplant (LT) waitlist and the impact of dynamic performance status changes on posttransplant outcomes remain understudied. Methods. This US nationwide retrospective cohort study analyzed adult LT candidates listed between 2015 and 2023. Trends in the proportion of low Karnofsky Performance Status (KPS) at listing and LT were analyzed. The trend in ΔKPS, representing the change in KPS between waitlisting and LT, was evaluated using linear regression, and its impact on post-LT mortality was estimated using Cox proportional hazards models. Inverse probability censoring weighting accounted for selection bias from death or dropout before LT. Results. Among 57 917 LT candidates, 39.5% had a low KPS (10%–40%) at listing. The likelihood of low KPS at waitlisting increased during the study period; however, there was a significant improvement in KPS at LT (P < 0.001). Amount of improvement in KPS (ΔKPS) significantly increased over time, by 0.5 points per month (P < 0.001), with the effect being approximately 3 times greater in patients with Model for End-Stage Liver Disease (MELD) score of <30 than those with MELD score of ≥30. A 10% increase in KPS between waitlisting and LT reduced the hazard of death post-LT by 5% (hazard ratio, 0.95; 95% confidence interval, 0.93-0.97). Conclusions. Although the transplant community has mitigated low KPS on the LT waitlist, optimizing post-LT outcomes, only modest improvement was seen in patients with high (≥30) MELD scores at listing. These findings highlight the need to enhance functional status in LT candidates and ensure timely transplants for patients with high MELD scores.