A Refined Lung Transplant Frailty Scale Incorporating Serum Albumin Is Associated With Risk of Mortality in Lung Transplant Candidates
- 1Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco
Abstract
BackgroundThe Lung Transplant Frailty Scale (LT-FS) is a validated binary measure of frailty in lung transplant candidates. We aimed to refine the LT-FS Base and Body Composition measures by developing a three-category classification to improve clinical risk stratification with serum albumin as a more clinically practical frailty biomarker.
MethodsTo develop the refined LT-FS, we applied a 4-step measure development method to a multicenter prospective cohort study of lung transplant candidates. Low albumin (<3.5 g/dL) replaced high serum C-reactive protein ([≥]10 mg/L) as the LT-FS biomarker. Cutpoints that balanced discrimination, risk prediction, and calibration were identified to define "frail", "pre-frail", and "not frail" categories. Next, we evaluated associations between the refined LT-FS and exercise capacity, patient-reported outcomes, and mortality using multivariate linear and Cox regression.
ResultsAmong 419 participants, the refined LT-FS identified a graded increase in mortality risk across frailty categories. For example, compared with candidates who were not frail, pre-frailty and frailty by the LT-FS Body Composition were associated with a 2.9-fold (HR 2.9, 95% CI 1.2-6.9) and 7-fold (HR 6.9, 95% CI 2.6-18.2) higher risk of waitlist delisting or death, respectively. Pre-frailty and frailty by LT-FS Body Composition were associated with 2-fold (HR 2.1, 95% CI 1.2-3.8) and 3.6-fold (HR 3.6, 95% CI 1.8-7.3) higher risk of mortality after transplant. Relationships with exercise capacity and patient-reported disability were less consistent.
ConclusionsA refined Lung Transplant Frailty Scale incorporating serum albumin demonstrates strong associations with waitlist and post-transplant mortality. The addition of a pre-frail category better captures the continuum of frailty and improves clinical risk stratification of lung transplant candidates.
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BibTeX
@misc{sriram2026refined,
title = {{A Refined Lung Transplant Frailty Scale Incorporating Serum Albumin Is Associated With Risk of Mortality in Lung Transplant Candidates}},
author = {A. Sriram and J. Christie and M. R. Anderson and L. Benvenuto and Y. Gao and S. M. Arcasoy and D. Calabrese and S. R. Hays and J. Kukreja and A. Venado and L. Betancourt and P. Gambetta and H. Scott and M. Oyster and D. Zaleski and J. Adler and L. Kalman and S. Patel and M. Tevald and K. E. Covinsky and C.-Y. Huang and J. R. Greenland and P. Katz and J. P. Singer},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.08.26365085},
url = {https://www.medrxiv.org/content/10.64898/2026.10.08.26365085v1},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - A Refined Lung Transplant Frailty Scale Incorporating Serum Albumin Is Associated With Risk of Mortality in Lung Transplant Candidates
AU - A. Sriram
AU - J. Christie
AU - M. R. Anderson
AU - L. Benvenuto
AU - Y. Gao
AU - S. M. Arcasoy
AU - D. Calabrese
AU - S. R. Hays
AU - J. Kukreja
AU - A. Venado
AU - L. Betancourt
AU - P. Gambetta
AU - H. Scott
AU - M. Oyster
AU - D. Zaleski
AU - J. Adler
AU - L. Kalman
AU - S. Patel
AU - M. Tevald
AU - K. E. Covinsky
AU - C.-Y. Huang
AU - J. R. Greenland
AU - P. Katz
AU - J. P. Singer
PY - 2026
DA - 2026/10/08
PB - medRxiv
DO - 10.64898/2026.10.08.26365085
UR - https://www.medrxiv.org/content/10.64898/2026.10.08.26365085v1
AB - BackgroundThe Lung Transplant Frailty Scale (LT-FS) is a validated binary measure of frailty in lung transplant candidates. We aimed to refine the LT-FS Base and Body Composition measures by developing a three-category classification to improve clinical risk stratification with serum albumin as a more clinically practical frailty biomarker. MethodsTo develop the refined LT-FS, we applied a 4-step measure development method to a multicenter prospective cohort study of lung transplant candidates. Low albumin (<3.5 g/dL) replaced high serum C-reactive protein ([≥]10 mg/L) as the LT-FS biomarker. Cutpoints that balanced discrimination, risk prediction, and calibration were identified to define "frail", "pre-frail", and "not frail" categories. Next, we evaluated associations between the refined LT-FS and exercise capacity, patient-reported outcomes, and mortality using multivariate linear and Cox regression. ResultsAmong 419 participants, the refined LT-FS identified a graded increase in mortality risk across frailty categories. For example, compared with candidates who were not frail, pre-frailty and frailty by the LT-FS Body Composition were associated with a 2.9-fold (HR 2.9, 95% CI 1.2-6.9) and 7-fold (HR 6.9, 95% CI 2.6-18.2) higher risk of waitlist delisting or death, respectively. Pre-frailty and frailty by LT-FS Body Composition were associated with 2-fold (HR 2.1, 95% CI 1.2-3.8) and 3.6-fold (HR 3.6, 95% CI 1.8-7.3) higher risk of mortality after transplant. Relationships with exercise capacity and patient-reported disability were less consistent. ConclusionsA refined Lung Transplant Frailty Scale incorporating serum albumin demonstrates strong associations with waitlist and post-transplant mortality. The addition of a pre-frail category better captures the continuum of frailty and improves clinical risk stratification of lung transplant candidates.
ER -