# Frailty and liver transplant eligibility beyond MELD scores: integrating functional status into candidate selection

## TL;DR

This study shows that frailty, measured by the Clinical Frailty Scale, is a better predictor of liver transplant eligibility than the MELD score, especially in patients with lower MELD scores.

## Contribution

The study introduces frailty assessment as a novel and more accurate factor in liver transplant eligibility beyond traditional MELD-Na scores.

## Key findings

- Frailty status, measured by the Clinical Frailty Scale, was a stronger predictor of transplant eligibility than MELD-Na scores.
- Eligible patients had significantly better frailty status compared to ineligible patients, despite lower MELD scores.
- The Clinical Frailty Scale showed superior predictive accuracy (AUC 0.84) compared to MELD-Na (AUC 0.72).

## Abstract

The MELD score, while central to liver transplant prioritization, fails to capture frailty, an important predictor of transplant eligibility and outcomes.

To assess the impact of frailty on transplant eligibility and compare its predictive accuracy to MELD-Na.

We prospectively studied adults with cirrhosis referred to for transplant evaluation. Frailty was assessed using the Clinical Frailty Scale (CFS) by a multidisciplinary team, with adjudication for disagreements. Laboratory data were collected, MELD scores calculated, and transplant eligibility determined using our institutional framework. Correlation, logistic regression, and ROC analyses compared MELD and CFS in predicting eligibility.

Among 672 patients evaluated, 76 (11.3%) met the primary endpoint of transplant eligibility. Eligible patients had significantly lower MELD scores, but better frailty status compared with ineligible patients (mean CFS 3.2 vs. 5.8, p < 0.001). CFS correlated moderately with MELD (r = 0.62) and showed superior predictive accuracy for eligibility (AUC 0.84 vs. 0.72).

Frailty, assessed by the Clinical Frailty Scale, outperformed MELD-Na in predicting transplant eligibility and proved relevant even in low-MELD populations. These findings highlight frailty as a practical determinant of eligibility and a step toward standardized, evidence-based equitable selection frameworks.