Author: Kwon HM et al.
Anesthesiology, September 10, 2025. doi:10.1097/ALN.0000000000005747
This registry-based study investigated cardiovascular impairment in liver transplantation (LT) candidates with acute-on-chronic liver failure (ACLF). Among 710 patients, a significant proportion had elevated cardiac biomarkers: up to one-third with BNP >400 pg/mL (suggestive of acute heart failure) and over 12% with high-sensitivity troponin I (hsTnI) >10-fold the upper limit (indicating myocardial injury).
Using Shapley additive explanations (SHAP) analysis, both BNP and hsTnI were strongly predictive of post-LT mortality. Adding these biomarkers to existing ACLF risk models (NACSELD-ACLF, CLIF-C-OF, SALT-M) substantially improved predictive accuracy. The newly developed SALT-M_CARDIAC score raised the optimism-corrected C-index for 30-day mortality from 0.73 to 0.76 (P<0.001). A nomogram based on the updated score was also created for clinical application.
The findings underscore that cardiac impairment is common in ACLF patients and is a critical determinant of transplant outcomes. Incorporating cardiac biomarkers into standard risk models enhances post-LT survival prediction and highlights the importance of pre-LT cardiac evaluation.
What You Should Know
• One-third of ACLF patients showed biomarker evidence of heart failure or myocardial injury before LT.
• BNP and hsTnI were key predictors of post-transplant mortality.
• Incorporating cardiac biomarkers into existing ACLF risk models improved prognostic accuracy.
• The SALT-M_CARDIAC score outperformed the original SALT-M in predicting 30-day mortality.
• Early detection and management of cardiac dysfunction may improve LT outcomes.
Thank you to Anesthesiology for making this work available.