Pre-transplant lipase elevation: A single-center study of clinically significant pancreatitis in liver transplant candidates

Background: Elevated lipase is common in critically ill patients, including those awaiting liver transplantation (LT), but its clinical significance remains unclear. We assessed the relationship between pre-LT lipase elevation, radiographic (RP) or intraoperative pancreatitis (IOP), and post-LT outcomes. Methods: We included adults undergoing LT evaluation between 1/2015–3/2025 with lipase ≥78 U/L within 14 days of the relevant index event (transplant, listing, committee deferral/decline). RP was defined by imaging evidence of peripancreatic inflammation or necrosis and IOP by intraoperative findings. Kaplan-Meier and Cox regression evaluated associations with post-LT death or graft failure. Results: Among 90 transplanted patients (median age 57, 60% male), 22% died or experienced graft failure within 36 months. RP or IOP occurred in 9% of patients; all IOP cases died within two months, while 60% of RP patients died within 19 months. At 60 days post-LT, isolated lipase elevation ≥3xULN was not associated with death or graft failure (HR 1.68, p =0.61), whereas RP was strongly associated with death or graft failure (HR 5.13, p =0.04). Lipase ≥5xULN predicted RP/IOP (OR 6.92, p =0.002) across the transplanted, waitlisted, and declined/deferred cohorts. Conclusion: In LT candidates, RP or IOP, but not isolated biochemical lipase elevation, is a significant predictor of post-LT death or graft failure. Lipase ≥5xULN warrants further imaging to identify clinically significant pancreatitis and optimize perioperative management.