Authors: Kwon H-M et al.
Journal: Anesthesiology, December 2, 2025. DOI: 10.1097/ALN.0000000000005747
Summary
This retrospective registry-based study evaluated whether incorporating cardiac biomarkers into existing risk models improves prediction of post–liver transplant mortality in patients with acute-on-chronic liver failure (ACLF). Cardiovascular complications are the leading cause of death after liver transplantation in this population, yet commonly used ACLF risk scores rely largely on hemodynamics and medication use without directly assessing myocardial injury or heart failure.
Using data from the ASAN–Liver Transplant Registry, 710 consecutive patients with ACLF who underwent liver transplantation were analyzed. Cardiac dysfunction was assessed preoperatively with B-type natriuretic peptide (BNP) as a marker of heart failure and high-sensitivity troponin I (hsTnI) as a marker of myocardial injury. A substantial proportion of high-risk ACLF patients demonstrated evidence of significant cardiac impairment, with elevated BNP levels suggestive of acute heart failure and markedly elevated hsTnI levels indicating myocardial injury.
Feature importance analysis identified BNP and hsTnI as strong independent predictors of posttransplant mortality. When cardiac biomarkers were added to established ACLF prognostic models, predictive performance for 30-day mortality improved meaningfully. Building on these findings, the authors modified the existing SALT-M score to create the SALT-M_CARDIAC model, which demonstrated superior discrimination and calibration for early posttransplant mortality. A nomogram was developed to facilitate bedside application.
The study highlights the high prevalence of occult cardiac dysfunction in ACLF and demonstrates that direct assessment of cardiac injury and heart failure meaningfully refines perioperative risk stratification. These findings support more systematic cardiac evaluation and optimization before liver transplantation in patients with ACLF.
Key Points
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Cardiac dysfunction is common in patients with acute-on-chronic liver failure undergoing liver transplantation.
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Elevated BNP and hsTnI levels independently predict posttransplant mortality.
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Existing ACLF risk models improve when cardiac biomarkers are incorporated.
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The SALT-M_CARDIAC score outperformed the original SALT-M score for predicting 30-day mortality.
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Cardiac injury and heart failure are critical, underrecognized determinants of post–liver transplant outcomes.
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Results support enhanced cardiac assessment and optimization in ACLF transplant candidates.
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