Risk Prediction Models for Post‐Operative Mortality in Patients With Cirrhosis

Abstract

Background and Aims Patients with cirrhosis are at increased risk of postoperative mortality. Currently available tools to predict postoperative risk are suboptimally calibrated and do not account for surgery type. Our objective was to use population‐level data to derive and internally validate cirrhosis surgical risk models. Approach and Results We conducted a retrospective cohort study using data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) cohort, which contains granular data on patients with cirrhosis from 128 U.S. medical centers, merged with the Veterans Affairs Surgical Quality Improvement Program (VASQIP) to identify surgical procedures. We categorized surgeries as abdominal wall, vascular, abdominal, cardiac, chest, or orthopedic and used multivariable logistic regression to model 30‐, 90‐, and 180‐day postoperative mortality (VOCAL‐Penn models). We compared model discrimination and calibration of VOCAL‐Penn to the Mayo Risk Score (MRS), Model for End‐Stage Liver Disease (MELD), Model for End‐Stage Liver Disease‐Sodium MELD‐Na, and Child‐Turcotte‐Pugh (CTP) scores. We identified 4,712 surgical procedures in 3,785 patients with cirrhosis. The VOCAL‐Penn models were derived and internally validated with excellent discrimination (30‐day postoperative mortality C‐statistic = 0.859; 95% confidence interval [CI], 0.809‐0.909). Predictors included age, preoperative albumin, platelet count, bilirubin, surgery category, emergency indication, fatty liver disease, American Society of Anesthesiologists classification, and obesity. Model performance was superior to MELD, MELD‐Na, CTP, and MRS at all time points (e.g., 30‐day postoperative mortality C‐statistic for MRS = 0.766; 95% CI, 0.676‐0.855) in terms of discrimination and calibration. Conclusions The VOCAL‐Penn models substantially improve postoperative mortality predictions in patients with cirrhosis. These models may be applied in practice to improve preoperative risk stratification and optimize patient selection for surgical procedures (http://www.vocalpennscore.com).

Frailty Is a Risk Factor for Postoperative Mortality in Patients With Cirrhosis Undergoing Diverse Major Surgeries

“…We created models for MELD, MELD-Na, CTP, the MRS, (6) and the VOCAL-Penn risk score. (4) Outcomes in logistic regression were 30-day, 90-day, and 180-day postoperative mortality. Of note, the MRS does not provide a discrete postoperative mortality prediction at 180 days, and as such no model was performed for this time point.…”

Análise epidemiológica dos óbitos por Doença Hepática Alcoólica entre 2006 e 2015 no Rio Grande do Sul

“…O CHC é, muitas vezes, diagnosticado tardiamente, pois apresentase de forma silenciosa e pouco sintomática (Atkins et al, 2014) (Kansagara et al, 2014) (Ganne-Carrié & Nahon, 2019. O prognóstico dos pacientes com esse tumor apresenta curso desfavorável, com uma taxa de sobrevivência em cinco anos de 18% (Villanueva, 2019) (Mahmud et al, 2020). Um estudo publicado em 2020, que buscou analisar os dados epidemiológicos de CHC no Brasil, evidenciou que a região Sul apresentou o maior número relativo de casos de CHC (> 20 casos / 100.000 habitantes) em comparação aos outros estados (Fernandes et al, 2020).…”

Value of Liver Function Tests in Cirrhosis

“…Albumin is an integral part of CTP score to assess prognosis in patient with cirrhosis. In a retrospective cohort study (VOCAL-Penn models) for post operative mortality in patients with cirrhosis, preoperative albumin alone is an important component in assessing post operative mortality (38) Patients with decompensated cirrhosis showed improve survival, less liver related complications, eases the management of ascites and reduces hospitalisations with long term albumin infusion hence cost-effective in these patients. Albumin level and its infusion post bleed reduces chances of rebleed in patients with cirrhosis and is used in the management of hepatorenal syndrome-acute kidney injury (HRS-AKI), spontaneous bacterial peritonitis and large volume paracentesis.…”