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Cardiac Biomarkers and Risk Stratification in Liver Transplantation for Acute-on-chronic Liver Failure: Refining
Hye-Mee Kwon1, Seong-Mi Yang1, Kyoung-Sun Kim1
1Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Anesthesiology
|September 10, 2025
Summary
Cardiac dysfunction is common in liver transplant patients with acute-on-chronic liver failure (ACLF). Incorporating cardiac biomarkers like BNP and hsTnI into risk scores significantly improves mortality prediction after liver transplant.
Area of Science:
- Cardiology
- Hepatology
- Transplant Surgery
Background:
- Cardiovascular complications are the primary cause of death post-liver transplant in acute-on-chronic liver failure (ACLF) patients.
- Existing risk models for ACLF patients undergoing liver transplant do not adequately assess cardiac injury.
- Cardiac dysfunction's role in mortality after liver transplant for ACLF is not fully understood.
Purpose of the Study:
- To evaluate the prevalence and impact of cardiac impairment in ACLF patients undergoing liver transplant.
- To develop an improved risk prediction model by incorporating cardiac biomarkers.
- To enhance the prediction of mortality after liver transplant in ACLF patients.
Main Methods:
- Prospective analysis of 710 ACLF patients from 2008-2019, measuring B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI).
- Assessment of heart failure and myocardial injury using established thresholds for BNP and hsTnI.
- Model performance evaluated using C-statistics, calibration metrics, and Shapley Additive exPlanations (SHAP) for feature importance.
Main Results:
- Significant prevalence of heart failure (32.5%) and myocardial injury (12.9%) in ACLF grade 3 patients.
- BNP and hsTnI were identified as key predictors of post-transplant mortality via SHAP analysis.
- Integration of cardiac biomarkers improved 30-day mortality prediction C-indices for existing models (e.g., NACSELD-ACLF from 0.68 to 0.75).
- The novel SALT-M_ CARDIAC score demonstrated superior predictive accuracy (optimism-corrected C-index 0.76) compared to the original SALT-M score (0.73).
Conclusions:
- Cardiac impairment is a significant and prevalent issue in ACLF patients awaiting liver transplant.
- The SALT-M_ CARDIAC score, incorporating cardiac biomarkers, offers improved risk stratification for mortality after liver transplant.
- Addressing cardiac dysfunction pre-transplant is critical for optimizing outcomes in ACLF patients.
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