Frailty is a well-established risk factor for poor outcomes in patients with cirrhosis awaiting liver transplantation (LT), but whether it predicts outcomes among those who have undergone LT is unknown.

Adult LT recipients from 8 US centers (2012–2019) were included. Pre-LT frailty was assessed in the ambulatory setting using the Liver Frailty Index (LFI). “Frail” was defined by an optimal cut point of LFI ≥ 4.5. We used the 75th percentile to define “prolonged” post-LT length of stay (LOS; ≥12 days), intensive care unit (ICU) days (≥4 days), and inpatient days within 90 post-LT days (≥17 days). Of 1166 LT recipients, 21% were frail pre-LT. Cumulative incidence of death at 1 and 5 years was 6% and 16% for frail and 4% and 10% for nonfrail patients (overall log-rank p = 0.02). Pre-LT frailty was associated with an unadjusted 62% increased risk of post-LT mortality (95% CI, 1.08–2.44); after adjustment for body mass index, HCC, donor age, and donation after cardiac death status, the HR was 2.13 (95% CI, 1.39–3.26). Patients who were frail versus nonfrail experienced a higher adjusted odds of prolonged LT LOS (OR, 2.00; 95% CI, 1.47–2.73), ICU stay (OR, 1.56; 95% CI, 1.12–2.14), inpatient days within 90 post-LT days (OR, 1.72; 95% CI, 1.25–2.37), and nonhome discharge (OR, 2.50; 95% CI, 1.58–3.97).

Compared with nonfrail patients, frail LT recipients had a higher risk of post-LT death and greater post-LT health care utilization, although overall post-LT survival was acceptable. These data lay the foundation to investigate whether targeting pre-LT frailty will improve post-LT outcomes and reduce resource utilization.