Changes in frailty are associated with waitlist mortality in patients with cirrhosis

Lai, Jennifer C.; Dodge, Jennifer L.; Kappus, Matthew R.; Dunn, Michael A.; Volk, Michael L.; Duarte‐Rojo, Andrés; Ganger, Daniel; Rahimi, Robert S.; McCulloch, Charles E.; Haugen, Christine E.; McAdams‐DeMarco, Mara; Ladner, Daniela P.; Segev, Dorry L.; Verna, Elizabeth C.

doi:10.1016/j.jhep.2020.03.029

Cited by 111 publications

(110 citation statements)

References 14 publications

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“…However, we did not evaluate changes in either frailty or performance status over time, which may be prognostically valuable. 7 , 25 , 35 A recent multi-center study by Lai et al 25 showed that patients who experienced improvements in frailty over time had a lower risk of death/delisting than patients who experienced worsening frailty, regardless of their baseline frailty and disease severity.…”

Section: Discussionmentioning

confidence: 99%

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Evaluating the Associations Between the Liver Frailty Index and Karnofsky Performance Status With Waitlist Mortality

Yao

Mohamad

et al. 2021

Transplantation Direct

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Background. Frailty has emerged as a critical determinant of mortality in patients with cirrhosis. Currently, the United Network for Organ Sharing registry only includes the Karnofsky Performance Status (KPS) scale, which captures a single component of frailty. We determined the associations between frailty, as measured by the Liver Frailty Index (LFI), and KPS with waitlist mortality. Methods. Included were 247 adult patients with cirrhosis listed for liver transplantation without hepatocellular carcinoma from February 2014 to June 2019, who underwent outpatient assessments using the LFI and KPS within 30 days of listing. “Frail” was defined using the established LFI cutoff of ≥4.4. Competing risk models assessed associations between the LFI and KPS with waitlist mortality (death/delisting for sickness). Results. At a median 8 months follow-up, 25 (10%) patients died/were delisted. In this cohort, median Model for End-Stage Liver Disease-Sodium was 17, LFI was 3.9 (interquartile range 3.4–4.5), and KPS was 80 (interquartile range 70–90). In multivariable analysis, LFI (sub-hazard ratio 1.07, per 0.1 unit; 95% confidence interval, 1.01-1.12) was associated with waitlist mortality while KPS was not (sub-hazard ratio 1.00, per 10 units; 95% confidence interval, 0.78-1.29). Conclusions. Our data suggest that frailty, as measured by the LFI, may be more appropriate at capturing mortality risk than KPS and provide evidence in support of using the LFI more broadly in clinical transplant practice in the outpatient setting.

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Section: Discussionmentioning

confidence: 99%

“…We have shown in several studies that the LFI is strongly associated with outcomes in patients with cirrhosis. 21 - 25 However, it is a performance-based metric that must be administered in person, raising concerns about its ability to be incorporated into the national UNOS/Organ Procurement and Transplantation Network registry.…”

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confidence: 99%

Evaluating the Associations Between the Liver Frailty Index and Karnofsky Performance Status With Waitlist Mortality

Yao

Mohamad

et al. 2021

Transplantation Direct

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“…( 39 ) Frailty may therefore be colinear with other important features of ACLF and, consequently, not contribute independently to mortality prediction. Finally, because changing frailty has been shown to predict death or delisting from the liver transplant waiting list, ( 40 ) it is possible that changes in frailty could also impact ACLF mortality.…”

Section: Discussionmentioning

confidence: 99%

Patient Frailty Is Independently Associated With the Risk of Hospitalization for Acute‐on‐Chronic Liver Failure

Sj¹,

Goldberg²,

Kaplan³

et al. 2020

Liver Transpl.

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There is significant interest in identifying risk factors associated with acute-on-chronic liver failure (ACLF). In transplant candidates, frailty predicts wait-list mortality and posttransplant outcomes. However, the impact of frailty on ACLF development and mortality is unknown. This was a retrospective study of US veterans with cirrhosis identified between 2008 and 2016. First hospitalizations were characterized as ACLF or non-ACLF admissions. Prehospitalization patient frailty was ascertained using a validated score based on administrative coding data. We used logistic regression to investigate the impact of an increasing frailty score on the odds of ACLF hospitalization and short-term ACLF mortality. Cox regression was used to analyze the association between frailty and longterm survival from hospitalization. We identified 16,561 cirrhosis hospitalizations over a median follow-up of 4.19 years (interquartile range, 2.47-6.34 years). In adjusted models, increasing frailty score was associated with significantly increased odds of ACLF hospitalization versus non-ACLF hospitalization (odds ratio, 1.03 per point; 95% CI 1.02-1.03; P < 0.001). By contrast, frailty score was not associated with ACLF 28-or 90-day mortality (P = 0.13 and P = 0.33, respectively). In an adjusted Cox analysis of all hospitalizations, increasing frailty scores were associated with poorer longterm survival from the time of hospitalization (hazard ratio, 1.02 per 5 points; 95% confidence interval, 1.01-1.03; P = 0.004). Frailty increases the likelihood of ACLF hospitalization among patients with cirrhosis, but it does not impact short-term ACLF mortality. These findings have implications for clinicians caring for frail outpatients with cirrhosis, including tailored follow-up, risk mitigation strategies, and possible expedited transplant evaluation.

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“…Third, because increasing frailty scores correlate with an increased risk of adverse outcomes, changes in frailty over time are meaningful in predicting future events. ( 8 ) The HFRS, however, is relatively static because it is calculated based on 2 years of preceding diagnostic codes which follow the patient in perpetuity.…”

Section: Can This Score Be Applied To Cirrhosis?mentioning

confidence: 99%

A Claims‐Based Frailty Risk Score Is Associated With Hospitalization for Acute‐on‐Chronic Liver Failure: But Is It Frailty?

Louissaint

Tapper

2020

Liver Transpl.

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Frailty is a multidimensional construct that broadly refers to a health state of diminished physiological reserve resulting in a reduced tolerance to health stressors. (1) Although the concept of frailty has its roots in geriatrics, it has flourished in hepatology. Indeed, many patients with cirrhosis are frail, which portends an increased risk of hospitalizations and mortality. (2,3) It is recommended that we evaluate all patients with decompensated cirrhosis or undergoing transplant evaluation for frailty with a toolbox that includes physical performance measures and validated disability scales. (1) Despite its importance, there are 3 persistent challenges facing frailty research. First, frailty assessments are infrequently used due to time constraints and the need for specialized tools or staff. (1) Second, because of the need for performance measures, population-based studies of frailty are lacking. Third, given the difficulties in assessing hospitalized patients for physical frailty, tools beyond disability measures are limited. (3) For all of these reasons, we welcome the important study by Shah et al. in this issue that examines the potential role of claims-based indices of frailty in chronic liver disease in a cohort of recently hospitalized patients with cirrhosis. (4)

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Changes in frailty are associated with waitlist mortality in patients with cirrhosis

Cited by 111 publications

References 14 publications

Evaluating the Associations Between the Liver Frailty Index and Karnofsky Performance Status With Waitlist Mortality

Evaluating the Associations Between the Liver Frailty Index and Karnofsky Performance Status With Waitlist Mortality

Patient Frailty Is Independently Associated With the Risk of Hospitalization for Acute‐on‐Chronic Liver Failure

A Claims‐Based Frailty Risk Score Is Associated With Hospitalization for Acute‐on‐Chronic Liver Failure: But Is It Frailty?

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