Screening for impaired liver function as a risk factor for drug safety at hospital admission of surgical patients

Strobach, Dorothea; Poppele, Angelika; Mannell, Hanna; Andraschko, Monika; Schiek, Susanne; Bertsche, Thilo

doi:10.1007/s11096-019-00948-7

Cited by 3 publications

(3 citation statements)

References 29 publications

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“…However, approximately 20% of all patients have elevated LLP without known liver disease, but only about 1% of those develop a hepatic disease within the next few years 52 . In a previous study, we found clinically relevant elevated LLP in 11% of surgical patients at hospital admission 51 …”

Section: Discussionmentioning

confidence: 64%

“…3,20 We found contraindicated drugs and inappropriate dosage adjustment in 2% and 3% of surgical patients admitted to hospital respectively. 51 In this study, in patients with MELD ≥7.5 bile or liver diagnoses were documented for 36% which corresponds to 10% referred to all patients. However, the real number might be higher since we did only search for the diagnoses in this subgroup.…”

Section: Clinical Interpretation Of Meld Screeningmentioning

confidence: 91%

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Feasibility of the MELD score as a screening tool for pharmacists to identify patients with impaired hepatic function at hospital admission

Golla

Mannell

Benesic

et al. 2022

Clinical Pharmacy Therapeu

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What is known and Objective Hepatic impairment (HI) is a known risk factor for drug safety. The MELD score (Model‐for‐endstage‐liver‐disease), calculated from serum creatinine, bilirubin and International Normalized Ratio (INR), is a promising screening tool corresponding to Child‐Pugh Score (CPS) for drug adjustment. We tested the feasibility of MELD as an automatic screening tool accounting for correct calculation, interfering factors (IF) and detection of patients corresponding to CPS‐B/C potentially requiring drug adjustment. Methods We retrospectively calculated MELD for a 3‐month cohort of surgical patients and assessed need for adjustment of MELD parameters to standard values. IF for INR (oral anticoagulants) and serum creatinine (renal insufficiency (RI; eGFR<60 ml/min/1.73m²); as well as drugs elevating creatinine levels (DECL)) and the number of patients with MELD scores corresponding to CPS‐B/C were analysed. For MELD ≥7.5, liver and bile diagnoses were recorded. Results and discussion Of 1183 patients, MELD was calculable for 761 (64%; median 7.5, range 6.4–36.8). Parameters had to be adjusted for 690 (91%) patients. IF of parameters were RI in 172 (23%), INR‐elevating drugs in 105 (14%) and DECL in 33 (4%) patients. Of 335 (44%) patients with MELD ≥7.5, 122 (36%) had documented liver or bile diagnoses. MELD 10‐<15 (corresponding to CPS‐B) was found for 105 (14%), MELD ≥15 (corresponding to CPS‐C) for 66 (9%) of the 761 patients with a calculated MELD. Referred to all patients, drug adjustments due to possible HI were recommendable for 14% of patients with suspected CPS‐B/C. What is new and Conclusion MELD is a feasible screening tool for HI as a risk factor for drug safety at hospital admission when appropriately considering correct parameter adjustment and RI and INR‐elevating drugs as IF. Further evaluation of sensitivity and specificity is needed.

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Section: Discussionmentioning

confidence: 64%

Section: Clinical Interpretation Of Meld Screeningmentioning

confidence: 91%

Feasibility of the MELD score as a screening tool for pharmacists to identify patients with impaired hepatic function at hospital admission

Golla

Mannell

Benesic

et al. 2022

Clinical Pharmacy Therapeu

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“…Moreover, alternative screening tools, such as screening for elevated LLP and ALT or the use of analytical CPS (considering laboratory parameters of CPS only) as tested by our group and others, did not perform well in the identification of patients at risk, and may under-or overestimate the number of patients with HI [49,61,62]. Considering this and the results of our study presented here, we conclude that a safe identification of patients suffering from HI at hospital admission can currently only be ensured by a trained pharmacist who is able to identify all patient-specific aspects related to a possible HI.…”

Section: Discussionmentioning

confidence: 77%

Hepatic Impairment as a Risk Factor for Drug Safety: Suitability and Comparison of Four Liver Scores as Screening Tools

Golla,

Benesic,

Mannell

et al. 2023

JCM

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Hepatic impairment (HI) influences the pharmacokinetics and pharmacodynamics of drugs and represents an important risk factor for drug safety. A reliable screening tool for HI identification at hospital admission by pharmacists would be desirable but is currently lacking. Therefore, we tested four liver scores as potential screening instruments. We retrospectively recorded liver/bile diagnoses, symptoms and abnormalities (summarized as hepatic findings) of 200 surgical patients followed by an assessment of the relevance of these findings for drug therapy (rating). The agreement between the Model of Endstage Liver Disease (MELD), Non-alcoholic fatty liver disease fibrosis score (NFS), Fibrosis 4 index (FIB-4), and aspartate-aminotransferase to platelet ratio index (APRI) and the rating was quantified by Cohen’s Kappa. The performance of the scores in this setting was further evaluated by their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Of 200 patients, 18 (9%) had hepatic findings relevant for drug therapy. Fair agreement was found for FIB-4 and MELD and slight agreement for APRI and NFS compared to the rating. The highest values for sensitivity, specificity, PPV, and NPV were 41.2% (MELD), 99.3% (APRI), 66.7% (APRI), and 93.6% (MELD), respectively. Due to low performance, none of the scores can be recommended for clinical use as a single screening tool for HI at hospital admission.

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Evaluation of a clinical decision support alert to identify hepatic dysfunction and need for medication therapy adjustment in hospitalized patients

Nguyen,

Jacobs,

Tasnim

et al. 2024

American Journal of Health-System Pharmacy

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Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose To optimize the hepatic dysfunction alert tool at our institution to identify appropriate patients and minimize irrelevant alerts. Methods This single-center, retrospective review included adults hospitalized over a 1-month period for whom a hepatic dysfunction alert fired for a medication order placed in the electronic health record. The existing alert determines hepatic dysfunction based on laboratory tests. The primary objective was to determine the proportion of patients with an alert that was deemed to be clinically relevant. Alerts were considered relevant if the patient had a Child-Pugh score in class B or C and were ordered a medication with a hepatic warning from FDA or LiverTox. The performance of 14 alternative models was evaluated. Results A total of 1,541 alerts fired for 309 patients. Of these patients, 155 were randomly selected for the analysis, and the alert was deemed relevant in 86 patients (55%). Patients with relevant alerts were more likely to have documented liver disease and worsening measures on liver function tests. Of the alternative models evaluated, a model that excluded INR and albumin resulted in a 27% decrease in the number of alerts fired, of which 73% were relevant; however, it failed to identify 30% of patients with relevant hepatic dysfunction. None of the other models performed better. Conclusion The existing hepatic dysfunction clinical decision support tool correctly identifies patients with relevant hepatic dysfunction only 55% of the time. Alternative models were able to improve the rate of relevant results, but not without missing patients with relevant hepatic dysfunction.

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Screening for impaired liver function as a risk factor for drug safety at hospital admission of surgical patients

Cited by 3 publications

References 29 publications

Feasibility of the MELD score as a screening tool for pharmacists to identify patients with impaired hepatic function at hospital admission

Feasibility of the MELD score as a screening tool for pharmacists to identify patients with impaired hepatic function at hospital admission

Hepatic Impairment as a Risk Factor for Drug Safety: Suitability and Comparison of Four Liver Scores as Screening Tools

Evaluation of a clinical decision support alert to identify hepatic dysfunction and need for medication therapy adjustment in hospitalized patients

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