Table 2: Assessment Approach and Concerning Red Flags in Multisystem Evaluation for Heart Transplantation.

Organ System	Assessment Tools	Red Flags
Frailty	Modified Fried frailty phenotype[31]	Patients who meet ≥3 criteria
Nutritional status	Modified BMI (BMI kg/m2 x albumin gm/L)[34] Nutritional risk index[32] 1.519 × serum albumin (g/l) + 41.7 × (actual body weight [kg]/ideal body weight [kg])	Modified BMI <600 Nutritional risk index <97.5
Autonomic neuropathy	Orthostatic blood pressures COMPASS-31 questionnaire[28] Formal autonomic function tests	Orthostasis Modified BMI <600 Nutritional risk index <97.5
Peripheral neuropathy	Variant ATTR: Polyneuropathy disability score[28] EMG AL: EMG	Disability score ≥ III[28,47] Symptoms severe enough to limit ambulation[22]
Pulmonary disease	Chest X ray/CT—interstitial thickening, consolidations or nodules, pleural effusions, airway thickening[51]	AL: Exudative pleural effusions[67]
Gastrointestinal tract disease	Symptom screen[48] Nutritional status assessment[68] Assessment of fat malabsorption[50] Routine esophagogastroduodeonoscopy and colonoscopy with random biopsies[22] (unclear role – performed at some centres) Poor correlation of symptoms with functional studies[49]	Modified BMI <600 Nutritional risk index <97.5 GI bleeding
Hepatic disease	Consider liver biopsy if hepatomegaly or serum alkaline phosphatase >1.5 times normal.[52]	Interstitial amyloid deposition, not vascular deposits[48] Total bilirubin > 2mg/dl[63]
Renal disease	Consider renal biopsy if proteinuria present to distinguish causes, such as amyloidosis, light chain deposition disease and cast nephropathy[40] from diabetes or other intrinsic processes.	Proteinuria ≥500mg/day[23] Glomerular amyloid deposits, not vasculature[40]
Haematologic disease	Examine light chain response to pre-heart transplant therapies Review cytogenetics with oncologists	Light chains not responsive to therapy High-risk cytogenetics Active myeloma

AL = light chain; ATTR = transthyretin; EMG = electromyography.