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Development of a novel frailty index to predict mortality in patients with end‐stage liver disease
Open accessAbstract
Cirrhosis is characterized by muscle wasting, malnutrition, and functional decline that confer excess mortality not well quantified by the Model for End-Stage Liver Disease (MELD) Sodium (MELDNa) score. We aimed to develop a frailty index to capture these extrahepatic complications of cirrhosis and enhance mortality prediction in patients with cirrhosis. Consecutive outpatients listed for liver transplantation at a single transplant center without MELD exceptions were assessed with candidate frailty measures. Best subset selection analyses with Cox regression identified subsets of frailty measures that predicted waitlist mortality (=death or delisting because of sickness). We selected the frailty index by balancing statistical accuracy with clinical utility. The net reclassification index (NRI) evaluated the %patients correctly reclassified by adding the frailty index to MELDNa. Included were 536 patients with cirrhosis with median MELDNa of 18. One hundred seven (20%) died/were delisted. The final frailty index consisted of: grip strength, chair stands, and balance. The ability of MELDNa and the frailty index to correctly rank patients according to their 3-month waitlist mortality risk (i.e., concordance-statistic) was 0.80 and 0.76, respectively, but 0.82 for MELDNa+frailty index together. Compared with MELDNa alone, MELDNa+frailty index correctly reclassified 16% of deaths/delistings (P = 0.005) and 3% of nondeaths/delistings (P = 0.17) with a total NRI of 19% (P < 0.001). Compared to those with robust frailty index scores (<20th percentile), cirrhotics with poor frailty index scores (>80th percentile) were more impaired by gait speed, difficulty with Instrumental Activities of Daily Living, exhaustion, and low physical activity (P < 0.001 for each). CONCLUSION: Our frailty index for patients with cirrhosis, comprised of three performance-based metrics, has construct validity for the concept of frailty and improves risk prediction of waitlist mortality over MELDNa alone. (Hepatology 2017;66:564-574).
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“Finally, malnutrition [105], frailty [106, 107] and especially sarcopenia [108, 109, 110, 111] have become increasingly important in patients with advanced chronic liver disease and should be evaluated and treated in each patient.”
From Current treatment of non‐alcoholic fatty liver disease (2022) · cites this paper as [106]
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Citations
Cites
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BackgroundMethodInfluentialSelf-citationFrailty and Mortality in Kidney Transplant Recipients
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BackgroundSix-minute walk distance predicts mortality in liver transplant candidates
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“, hand grip strength, depression scale, and short gait speed) have the strong advantage of being easy to administer at baseline and longitudinally at the bedside, even in patients with cirrhosis.((2,5)) However, these measures were originally developed in cohorts of community-dwelling adults over age 65 years without…”
BackgroundInfluentialSelf-citationTapper, E. B., Finkelstein, D., Mittleman, M. A., Piatkowski, G., & Lai, M. (2015) · Hepatology · doi:10.1002/hep.27830 · Cited by 201 · cited 2×
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BackgroundDepression and Frailty in Patients With End-Stage Liver Disease Referred for Transplant Evaluation
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Background
Research works printed but not linked: 1
- 2005, Model building in PROC PHREG with automatic variable selection and information criteria, Stat Data Anal, SUGI 30, 206
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“(90,91) Poor performance according to some scales (e.g., ADLs), however, suggests a greater burden of functional deficits than others (e.g., walk speed).”
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Current treatment of non‐alcoholic fatty liver disease
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Metadata
- Authors
- Lai, J. C., Covinsky, K. E., Dodge, J. L., Boscardin, W. J., Segev, D. L., Roberts, J. P., & Feng, S.
- Affiliations
- University of California, San Francisco (US)
- Johns Hopkins University (US)
- Corresponding author
- Lai, Jennifer C.
- ORCID
- Venue
- Hepatology
- Published
- 2017-06-28
- Volume
- 66
- Issue
- 2
- Pages
- 564-574
- ISSN
- 0270-9139 (ISSN-L)
- 1527-3350
- PMC
- PMC5519430
- OpenAlex
- W2606209221
- Cited by
- 556
- References
- 34
- Citations by year
- 2026: 75 · 2025: 62 · 2024: 71 · 2023: 62 · 2022: 50 · 2021: 69 · 2020: 60 · 2019: 59 · 2018: 35 · 2017: 10
- FWCI
- 27.72
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Hepatology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- American College of Gastroenterology (K23AG048337, P30 DK026743, P30AG044281)
- National Institutes of Health
- University of California, San Francisco (P30 AG044281, P30DK026743)
- National Institute on Aging (K23AG048337, R01AG042504, R03AG045072, P30AG044281)
- National Institute of Diabetes and Digestive and Kidney Diseases (K24DK101828, P30DK026743)
- Liver Center, University of California, San Francisco (P30 DK026743, DK026743)
- Topics
- Health Sciences › Medicine › Hepatology › Liver Disease and Transplantation
- Health Sciences › Medicine › Geriatrics and Gerontology › Frailty in Older Adults
- Health Sciences › Medicine › Hepatology › Liver Disease Diagnosis and Treatment
- Keywords
- frailty index, end-stage liver disease, liver cirrhosis, waitlist mortality, MELD-Na, liver transplantation, mortality prediction, grip strength, chair stand, balance, net reclassification improvement, instrumental activities of daily living, walking speed, exhaustion, physical activity
- MeSH terms
- Activities of Daily Living, Cause of Death, Disability Evaluation, Female, Humans, Liver Cirrhosis, Male, Middle Aged, Physical Fitness, Predictive Value of Tests, Prognosis, Retrospective Studies, Severity of Illness Index, Waiting Lists, Reproducibility of Results, Cohort Studies, Survival Rate, Liver Transplantation, Databases, Factual, Risk Assessment, End Stage Liver Disease
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