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

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. We included adults undergoing LT evaluation between January 2015 and March 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. 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 2 months, while 60% of RP patients died within 19 months. At 60 days post-LT, isolated lipase elevation ≥3×ULN 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 ≥5×ULN predicted RP/IOP (OR 6.92, p =0.002) across the transplanted, waitlisted, and declined/deferred cohorts. In LT candidates, RP or IOP, but not isolated biochemical lipase elevation, is a significant predictor of post-LT death or graft failure. Lipase ≥5×ULN warrants further imaging to identify clinically significant pancreatitis and optimize perioperative management.