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

BACKGROUND: The MELD score, while central to liver transplant prioritization, fails to capture frailty, an important predictor of transplant eligibility and outcomes. AIM: To assess the impact of frailty on transplant eligibility and compare its predictive accuracy to MELD-Na. METHODS: 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. RESULTS: 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). CONCLUSION: 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.