Multimarker Composite Prediction of Early Allograft Dysfunction and 90-Day Mortality After Liver Transplantation: Development and Internal Validation of the DLC Score

Background/Object: Early allograft dysfunction (EAD) and 90-day mortality are major challenges after liver transplantation (LT). Combined predictive utility of the delta neutrophil index (DNI), lactate clearance, and C-reactive protein/albumin ratio (CAR) in the post-LT setting remains unexplored. Methods: We conducted a single-center retrospective cohort study of 548 adult elective LT recipients (January 2010–December 2023). Serial DNI, lactate clearance, CRP, albumin, bilirubin, and INR were measured during the first postoperative week. Multivariate logistic regression identified MELD score and five postoperative predictors of 90-day mortality: Results: DNI ≥ 2.5 at POD 7 (OR 8.42, 95% CI 3.56–19.92), lactate clearance < 15% at 6 h post-reperfusion (OR 4.65), CRP/albumin ratio ≥ 8.5 at POD 3 (OR 3.28), total bilirubin ≥ 10 mg/dL at POD 7 (OR 2.94), and INR ≥ 1.6 at POD 7 (OR 2.18). A five-variable postoperative DLC composite score (0–5 points) achieved an AUC of 0.876 (95% CI 0.831–0.921) for 90-day mortality, significantly outperforming DNI alone (AUC 0.742), MELD (AUC 0.663; both p < 0.001), and a bilirubin/INR subset of the Olthoff EAD criteria (AUC 0.784; p = 0.014). In a secondary concordance analysis, the DLC score showed concordance with patients meeting EAD criteria (AUC 0.854). Risk stratification produced 90-day mortality of 2.7%, 18.4%, and 55.3% for Low-, Intermediate-, and High-risk groups. Conclusions: The DLC score demonstrates promising internal performance for risk stratification within the first postoperative week and warrants prospective external validation prior to clinical adoption.