Risk Factors for Failure to Rescue in Adult Liver Transplantation Recipients: A Systematic Review

Failure to rescue (FTR), defined as death following major complications, has become an important quality metric. While liver transplantation (LT) carries high risks for postoperative complications, the relevance and determinants of FTR in LT remain poorly characterized. This systematic review aimed to identify the incidence and risk factors for FTR in adult liver transplant recipients.

Following PRISMA guidelines, a systematic literature search was performed across four databases: MEDLINE Ovid, Web of Science, Cochrane CENTRAL, and Scopus. Studies reporting FTR rates and associated risk factors in adult LT recipients were included. Data extraction and quality assessment were performed independently by two reviewers.

Four studies met the inclusion criteria, representing a total of 13,710 liver transplant cases. Definitions of FTR varied across studies, leading to heterogeneity in reported incidence: 5.0%, 9.8%, 19.3%, and 39.6%. Identified risk factors included patient-related factors, such as low total psoas area (a proxy for sarcopenia), increased recipient age, and early allograft dysfunction, and center-related factors, such as low-volume center. One multicenter study reported significant variation in FTR rates across Human Development Index levels, though it did not assess individual-level predictors. Study quality ranged from moderate to high, but all were limited by inconsistent FTR definitions and heterogeneous study designs.

Despite increasing recognition of FTR as a quality metric, evidence in liver transplantation remains limited. Sarcopenia, early allograft dysfunction, and socioeconomic disparities may contribute to FTR, but current findings are insufficient for robust conclusions. Future research should aim to standardize FTR definitions and conduct multicenter prospective studies to clarify modifiable factors and improve post-transplant outcomes.