Preoperative C-Reactive Protein-to-Albumin Ratio Predicts Recipient and Graft Survival After Deceased-Donor Liver Transplantation.

Background/Objectives: Recipient-related factors continue to influence long-term outcomes after deceased-donor liver transplantation (DDLT). This study evaluated the prognostic value of the preoperative C-reactive protein-to-albumin ratio (CAR) for recipient survival (RS) and graft survival (GS). Methods: Adult patients undergoing DDLT between 2010 and 2023 were retrospectively analyzed. Re-transplantations, split or domino transplants, patients who died within 90 days and patients with early allograft dysfunction were excluded. Primary endpoints were 3-year RS and GS. Receiver operating characteristic analysis was used to determine the optimal CAR cut-off. Survival was assessed using Kaplan-Meier analysis and Cox regression. Results: A total of 330 patients were included. Mean RS and GS were 112 months (95%CI 106-119) and 110 months (95%CI 103-116), respectively. Preoperative CAR demonstrated the strongest predictive value for 3-year RS (AUC = 0.70, p < 0.001) and GS (AUC = 0.71, p < 0.001). A CAR cut-off of 41% provided optimal discrimination. Patients with CAR > 41% had significantly reduced 3-year RS (31 vs. 34 months, p < 0.001) and GS (30 vs. 34 months, p < 0.001). CAR > 41% was independently associated with increased risk of 3-year mortality (HR 2.101, 95%CI 1.277-3.456, p = 0.003) and graft loss (HR 3.666, 95%CI 1.804-7.449, p < 0.001). Similar results were observed for 5-year outcomes. Conclusions: Elevated preoperative CAR is independently associated with inferior patient and graft survival and may enhance risk stratification after DDLT.