Hypoalbuminemia is Associated With Significantly Higher Liver Transplant Waitlist Mortality and Lower Probability of Receiving Liver Transplant

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To evaluate the predictive value of hypoalbuminemia on liver transplant (LT) waitlist survival and probability of receiving LT among adults with end-stage liver disease (ESLD).


Growing evidence reports on the negative prognostic value of hypoalbuminemia among ESLD patients awaiting LT.


Using 2003 to 2015 United Network for Organ Sharing data, we retrospectively evaluated the impact of mild-moderate (2.5 to 3.4 g/dL) and severe hypoalbuminemia (<2.5 g/dL) on waitlist survival and probability of receiving LT among US adults awaiting LT. Outcomes were stratified by liver disease etiology and presence of hepatocellular carcinoma (HCC), and evaluated using Kaplan-Meier and multivariate Cox proportional hazards models.


Among 128,450 adults listed for LT, 27.1% had normal albumin (≥3.5 g/dL), 53.7% mild-moderate hypoalbuminemia (2.5 to 3.4 g/dL), and 19.2% severe hypoalbuminemia (<2.5 g/dL) at time of listing. Patients with severe hypoalbuminemia had significantly lower 1-year waitlist survival compared with those with normal albumin (80.4% vs. 95.2%; P<0.001). On multivariate regression, severity of hypoalbuminemia was associated with increasing waitlist mortality, even after correcting for model for end stage liver disease-sodium and HCC [albumin, 2.5 to 3.4 g/dL: hazard ratio (HR), 1.81; 95% confidence interval (CI), 1.62-2.01; P<0.001; <2.5 g/dL: HR, 2.46; 95% CI, 2.20-2.76; P<0.001]. Patients with hypoalbuminemia had significantly lower probability of receiving LT compared with those with normal albumin (albumin <2.5 g/dL: HR, 0.80; 95% CI, 0.78-0.83; P<0.001).


ESLD patients with hypoalbuminemia have lower probability of LT despite significantly higher waitlist mortality compared with patients with normal albumin. If validated by further studies, incorporation of albumin into prognostication systems may improve the performance of US donor organ allocation systems.

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