Authors: Kwon, Hye-Mee et al.
Anesthesiology, September 10, 2025. DOI: 10.1097/ALN.0000000000005747
This study examined the role of cardiac dysfunction in predicting outcomes following liver transplantation (LT) in patients with acute-on-chronic liver failure (ACLF). Cardiovascular complications remain a leading cause of post-transplant mortality in this population, yet existing risk models primarily assess circulatory failure through hemodynamic parameters and medication use, not direct cardiac biomarkers.
Researchers analyzed 710 consecutive ACLF patients from the ASAN-LT Registry (2008–2019), including those meeting CLIF-C and NACSELD-ACLF criteria. Cardiac impairment was evaluated using B-type natriuretic peptide (BNP) to indicate heart failure and high-sensitivity troponin I (hsTnI) to detect myocardial injury. These biomarkers were incorporated into existing risk models, resulting in the development of an enhanced predictive tool, the SALT-M_CARDIAC score.
Results showed that over one-third of high-grade ACLF patients exhibited evidence of heart failure (BNP >400 pg/mL), and about 13% had severe myocardial injury (hsTnI >10× the upper limit of normal). Both BNP and hsTnI were identified through Shapley additive explanations (SHAP) analysis as strong predictors of 30-day mortality. Incorporating these biomarkers improved the predictive accuracy of multiple models: the C-index for 30-day mortality rose from 0.68 to 0.75 for NACSELD-ACLF and from 0.73 to 0.76 for the SALT-M_CARDIAC score. A nomogram was also created to facilitate individualized survival prediction after transplantation.
These findings underscore that cardiac impairment is both common and clinically significant in ACLF patients undergoing LT. Early identification and management of cardiac dysfunction using BNP and hsTnI can improve perioperative risk assessment and post-transplant survival.
What You Should Know:
The SALT-M_CARDIAC score enhances traditional ACLF risk models by integrating cardiac biomarkers, allowing more accurate prediction of 30-day post-transplant mortality. Pretransplant cardiac evaluation using BNP and hsTnI may be essential to optimizing patient selection and improving outcomes.
Thank you to Anesthesiology for highlighting this significant advancement in cardiac risk assessment for liver transplant candidates with ACLF.