Multidimensional Frailty Assessment and Post-Transplant Outcomes in Liver Transplant Candidates

Investigation of the Relationship Between Frailty, Sarcopenia, Malnutrition, and Psychosocial Parameters and Post-Transplant Outcomes in Liver Transplant Candidates

This study will evaluate frailty, nutrition, sarcopenia, and psychological health in people waiting for a liver transplant. The purpose is to understand how these factors affect outcomes before and after transplantation. By identifying patients at higher risk early, the study aims to support the development of better care programs in the future.

Participants will complete simple tests of physical strength, walking speed, and daily activity levels. Their nutrition and psychological well-being will also be assessed. The study will then look at how these results relate to medical scores used in liver disease and to outcomes after transplant, such as hospital stay, complications, or survival.

Adults aged 18-65 years who are on the liver transplant waiting list and can understand Turkish are eligible to join.

Study Overview

• Status: Recruiting
• Conditions: Liver Transplantation; Cirrhosis; End-Stage Liver Disease
• Intervention / Treatment: Other: Comprehensive Observational Assessment in Liver Transplant Candidates

• Study Type: Observational
• Enrollment (Estimated): 60

Contacts and Locations

• Study Contact: Name: Assistant Professor; Phone Number: 14046; Email: ayse.vatansever@bakircay.edu.tr

Study Locations

• Turkey (Türkiye)
  • Izmir, Turkey (Türkiye)
    • Recruiting
    • Izmir University of Economics Medical Point Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

The study population consists of patients listed as liver transplant candidates at a private hospital in Izmir, Turkey.

Description

Inclusion Criteria:

• Being listed as a liver transplant candidate
• Age between 18 and 65 years
• Ability to understand the Turkish language

Exclusion Criteria:

• Presence of orthopedic and/or neurological problems severe enough to prevent completion of assessment tools
• Inability to understand verbal commands
• Being a recipient of multiple organ transplants
• Presence of serious active extrahepatic malignancy

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

Adult Liver Transplant Candidates; This cohort includes adult patients (aged 18-65 years) who are on the liver transplant waiting list and able to understand Turkish. Participants will undergo assessments of frailty, sarcopenia, malnutrition, and psychosocial health. No therapeutic intervention will be applied; this is an observational study. Clinical outcomes after transplantation, such as length of ICU stay, hospital discharge time, complications, and survival, will be recorded prospectively.

Other: Comprehensive Observational Assessment in Liver Transplant Candidates; This study involves a comprehensive, multidimensional assessment of liver transplant candidates focusing on frailty, sarcopenia, malnutrition, and psychosocial status. Frailty will be measured using the Liver Frailty Index (LFI), 6-Minute Walk Test (6MWT), Karnofsky Performance Status (KPS), and Activities of Daily Living (ADL). Sarcopenia will be evaluated through handgrip strength, Appendicular Skeletal Muscle Mass (ASM)/Skeletal Muscle Index (SMI), and 4-meter gait speed. Malnutrition will be assessed using the Nutritional Risk Index (NRI) and phase angle derived from bioelectrical impedance analysis. Psychosocial status will be measured with the Hospital Anxiety and Depression Scale (HADS). Clinical parameters (MELD-Na, Child-Pugh, CKI-OKN) will be recorded. Post-transplant adverse outcomes including prolonged hospital and ICU stay, postoperative complications, early mortality, and duration of mechanical ventilation will be monitored up to 30 days after surgery.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Liver Frailty Index (LFI)	Frailty will be assessed using the Liver Frailty Index (LFI), which is calculated from three standardized physical performance tests: grip strength (kg, average of three trials), chair stands (seconds to complete five repetitions), and balance test (seconds, up to 10 seconds in three positions). LFI score will be calculated according to the standard LFI formula. Frailty severity will be categorized as: ≥4.5: Severe frailty 3.2-4.4: Moderate frailty <3.2: Not frail Unit of Measure: LFI score (continuous) Direction: Higher scores indicate greater frailty (worse outcome).	At hospital admission when liver transplantation is confirmed.
6-Minute Walk Test (6MWT) Distance	The 6-minute walk test (6MWT) will be conducted according to European Respiratory Society and American Thoracic Society guidelines along a 30-meter corridor. Participants will be instructed to walk as far as possible in six minutes. Distance walked will be recorded in meters and rounded to the nearest meter. Oxygen saturation, heart rate, blood pressure, and fatigue (Modified Borg Scale) will be recorded before and after the test, with continuous SpO₂ and heart rate monitoring during the walk. Frailty classification will be based on the following thresholds: <250 m (severe frailty), 250-350 m (moderate frailty), >350 m (not frail). Unit of Measure: Meters (continuous) Direction: Higher walking distance indicates lower frailty (better outcome).	At hospital admission when liver transplantation is confirmed.
Karnofsky Performance Status (KPS)	The Karnofsky Performance Status (KPS) is a subjective measure of frailty, originally developed for oncology and subsequently applied in cirrhosis. The scale ranges from 0% (death) to 100% (normal; no complaints; no evidence of disease), scored in 10-point increments. Applicable to both hospitalized and ambulatory patients. Frailty classification will be based on the following thresholds: 0-40% = Severe frailty 50-70% = Moderate frailty ≥80% = Not frail Unit of Measure: Percentage (%) Direction: Higher KPS score indicates lower frailty (better outcome).	At hospital admission when liver transplantation is confirmed.
Activities of Daily Living (ADL)	The Activities of Daily Living (ADL) scale is a subjective measure of frailty, developed to assess functional status in aging populations. It evaluates six functions: bathing, dressing, toileting, continence, transferring, and feeding. The scale is self-reported and scored from 0 (dependent) to 6 (independent). Frailty classification will be based on the following thresholds: ≥2 difficulties (severe frailty), 1 difficulty (moderate frailty), and 0 difficulties (not frail). Unit of Measure: Score (0-6) Direction: Higher scores indicate lower frailty (better outcome).	At hospital admission when liver transplantation is confirmed.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Nutritional Risk Index (NRI)	Nutritional status will be assessed using the Nutritional Risk Index (NRI). The NRI score will be calculated using serum albumin level (g/dL), current body weight (kg), and usual body weight (kg) according to the following formula: NRI = (15.19 × serum albumin [g/dL]) + (41.7 × current weight / usual weight) Nutritional status will be categorized as follows: NRI ≥ 100: No malnutrition 97.5 ≤ NRI < 100: Mild malnutrition 83.5 ≤ NRI < 97.5: Moderate malnutrition NRI < 83.5: Severe malnutrition Unit of Measure: NRI score Direction: Higher NRI values indicate better nutritional status.	At hospital admission when liver transplantation is confirmed.
Phase Angle Measured by Bioelectrical Impedance Analysis (BIA)	Phase angle will be measured using bioelectrical impedance analysis (BIA) as an indicator of cellular integrity and nutritional status. Measurements will be performed according to standard BIA procedures at the time of hospital admission. Phase angle values will be categorized according to predefined study criteria as follows: <4.4 degrees: Abnormal 4.4-5.4 degrees: Borderline ≥5.4 degrees: Normal Unit of Measure: Degrees Direction: Higher phase angle values indicate better cellular health and nutritional status.	At hospital admission when liver transplantation is confirmed.
Sarcopenia Diagnosis According to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) Criteria	Sarcopenia will be assessed according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria. Evaluation will include assessment of muscle strength, muscle mass, and physical performance using standardized measurement procedures at hospital admission. Sarcopenia will be classified as: Probable sarcopenia: Low muscle strength Sarcopenia: Low muscle strength and low muscle mass Severe sarcopenia: Low muscle strength, low muscle mass, and low physical performance Unit of Measure: Categorical classification (probable sarcopenia, sarcopenia, severe sarcopenia) Direction: Lower sarcopenia severity indicates better muscle status.	At hospital admission when liver transplantation is confirmed.
Handgrip Strength (HGS)	Handgrip strength will be measured using a hand dynamometer in the dominant hand following a standardized protocol (patient seated, elbow at 90 degrees, three trials, best value recorded). Low muscle strength will be defined according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria as <27 kg for men and <16 kg for women. Unit of Measure: Kilograms (kg) Direction: Higher handgrip strength indicates better muscle strength and physical status.	At hospital admission when liver transplantation is confirmed.
Skeletal Muscle Index (SMI)	Skeletal Muscle Index (SMI) will be assessed using bioelectrical impedance analysis (BIA). Appendicular skeletal muscle mass (ASM) will be calculated as the sum of muscle mass of the upper and lower extremities. SMI will be derived by dividing ASM (kg) by height squared (m²), according to the formula: SMI = ASM / height² Low muscle mass will be defined according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria as SMI <7.0 kg/m² for men and <5.5 kg/m² for women. Unit of Measure: kg/m² Direction: Higher SMI values indicate better skeletal muscle mass and physical status.	At hospital admission when liver transplantation is confirmed.
Gait Speed (4-meter walk test)	Gait speed will be measured using the 4-meter walk test. Participants will be instructed to walk at their usual pace over a 4-meter course, and time will be recorded with a stopwatch. Gait speed will be calculated as distance (4 m) divided by time (seconds) and expressed in m/s. Low physical performance will be defined according to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) criteria as gait speed ≤0.8 m/s. Unit of Measure: Meters per second (m/s) Direction: Higher gait speed indicates better physical performance.	At hospital admission when liver transplantation is confirmed.
Hospital Anxiety and Depression Scale - Anxiety Subscale (HADS-A)	Anxiety symptoms will be assessed using the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), which consists of 7 items. Each item is scored from 0 to 3, producing a total score ranging from 0 to 21. Higher scores indicate greater anxiety symptoms. A score of ≥10 will be considered indicative of clinically significant anxiety, based on the validated Turkish version of the scale. Unit of Measure: HADS-A score (0-21) Direction: Higher scores indicate higher anxiety symptoms (worse outcome).	At hospital admission when liver transplantation is confirmed.
Hospital Anxiety and Depression Scale - Depression Subscale (HADS-D)	Depressive symptoms will be assessed using the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D), which consists of 7 items. Each item is scored from 0 to 3, producing a total score ranging from 0 to 21. Higher scores indicate greater depressive symptoms. A score of ≥7 will be considered indicative of clinically significant depression, based on the validated Turkish version of the scale. Unit of Measure: HADS-D score (0-21) Direction: Higher scores indicate higher depressive symptoms (worse outcome).	At hospital admission when liver transplantation is confirmed.
Hospital Anxiety and Depression Scale - Total Score (HADS Total)	Psychological distress will be assessed using the Hospital Anxiety and Depression Scale (HADS), a 14-item self-report questionnaire. Each item is scored from 0 to 3, producing a total score ranging from 0 to 42. The total score is calculated as the sum of all items (HADS Total = HADS-A + HADS-D). No validated universal cut-off exists for the total score; therefore, it will be analyzed as a continuous variable. Unit of Measure: Total HADS score (0-42) Direction: Higher scores indicate greater psychological distress (worse outcome).	At hospital admission when liver transplantation is confirmed.
Charlson Comorbidity Index - Orthotopic Liver Transplant (CCI-OLT)	Comorbidity burden will be assessed using the Charlson Comorbidity Index modified for orthotopic liver transplant candidates (CCI-OLT). The index includes five comorbidities with the following weights: COPD (3 points), coronary artery disease (2 points), connective tissue disease (2 points), renal insufficiency (2 points), and diabetes mellitus (1 point). Renal insufficiency is defined as serum creatinine >1.5 mg/dL in the most recent preoperative test. The total CCI-OLT score will be calculated as the sum of the weighted comorbidities. Unit of Measure: CCI-OLT score (continuous) Direction: Higher scores indicate greater comorbidity burden (worse outcome).	At hospital admission when liver transplantation is confirmed.
Intensive Care Unit (ICU) Length of Stay	Length of stay in the intensive care unit (ICU) after orthotopic liver transplantation will be recorded. ICU stay duration will be calculated in days from the day of transplantation until discharge from the ICU. Unit of Measure: Days Direction: Shorter ICU stay indicates better outcome.	From the day of liver transplantation until ICU discharge (within 30 days post-transplant).
Hospital Length of Stay	Length of hospital stay after orthotopic liver transplantation will be recorded. Hospital stay duration will be calculated in days from the day of transplantation until hospital discharge. Unit of Measure: Days Direction: Shorter hospital stay indicates better outcome.	From the day of liver transplantation until hospital discharge (within 30 days post-transplant).
Postoperative Mechanical Ventilation Duration	Requirement for postoperative invasive mechanical ventilation after orthotopic liver transplantation will be recorded. Prolonged mechanical ventilation is defined as ventilation lasting ≥24 hours. Unit of Measure: Categorical (prolonged ventilation ≥24 hours vs <24 hours) Direction: Less prolonged mechanical ventilation indicates better outcome.	From the day of liver transplantation until extubation or 30 days post-transplant, whichever occurs first.
Early Postoperative Complications (within 30 days)	Incidence of early postoperative complications within 30 days after orthotopic liver transplantation will be recorded. Complications include infection, bleeding, biliary complications, and graft dysfunction. Complications will be reported as present or absent and categorized by type. Unit of Measure: Categorical (present/absent; type-specific) Direction: Fewer complications indicate better outcome.	Within 30 days after liver transplantation.
30-Day Mortality	Mortality status within 30 days after orthotopic liver transplantation will be recorded. Unit of Measure: Binary (alive vs deceased) Direction: Lower mortality indicates better outcome.	Within 30 days after liver transplantation.

Collaborators and Investigators

• Sponsor: Izmir Bakircay University
• Collaborators: Izmir University of Economics Medical Point Hospital

Study record dates

Study Major Dates

• Study Start (Actual): December 15, 2025
• Primary Completion (Estimated): August 1, 2026
• Study Completion (Estimated): August 1, 2026

Study Registration Dates

• First Submitted: January 28, 2026
• First Submitted That Met QC Criteria: February 12, 2026
• First Posted (Actual): February 17, 2026

Study Record Updates

• Last Update Posted (Actual): February 17, 2026
• Last Update Submitted That Met QC Criteria: February 12, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Keywords: Sarcopenia; Malnutrition; Frailty; Psychosocial Health; Liver Transplant Candidates
• Additional Relevant MeSH Terms: Neurologic Manifestations; Nervous System Diseases; Neuromuscular Manifestations; Pathologic Processes; Nutrition Disorders; Pathological Conditions, Anatomical; Digestive System Diseases; Liver Diseases; Muscular Atrophy; Atrophy; Liver Failure; Hepatic Insufficiency; Pathological Conditions, Signs and Symptoms; Nutritional and Metabolic Diseases; Signs and Symptoms; Frailty; Malnutrition; Fibrosis; Sarcopenia; End Stage Liver Disease
• Other Study ID Numbers: 2537