A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

Abstract

Identification of patients with cirrhosis at risk for death within 3 months of discharge from the hospital is essential to individualize postdischarge plans. The objective of the study was to identify an easy-to-use prognostic model based on the Karnofsky Performance Status (KPS). The North American Consortium for the Study of End-Stage Liver Disease consists of 16 tertiary-care hepatology centers that prospectively enroll nonelectively admitted cirrhosis patients. Patients enrolled had KPS assessed 1 week postdischarge. KPS was categorized into low (score 10-40), intermediate , and high (80-100). Of 954 middle-aged patients (57 6 10 years, 63% men) with a median Model for End-Stage Liver Disease (MELD) score of 17 (interquartile range 13-21), the mortality rates for the low, intermediate, and high performance status groups were 23% (36/ 159), 11% (55/489), and 5% (15/306), respectively. Low, intermediate, and high performance status was seen in 17%, 51%, and 32% of the cohort, respectively. Low performance status was associated with older age, dialysis, hepatic encephalopathy, longer length of stay, and higher white blood cell count or MELD score at discharge. A model was derived using the three independent predictors of 3-month mortality: KPS, age, and MELD score. This score had better discrimination (area under the receiver operating characteristic curve 5 0.74) than a model using MELD (area under the receiver operating characteristic curve 5 0.62) or MELD and age (area under the receiver operating characteristic curve 5 0.67) to predict 3-month mortality. Conclusions: Cirrhosis patients at risk for 3-month postdischarge mortality can be identified using a novel KPS-based score; this score may be adopted in practice to guide postdischarge early interventions, including the integrated provision of active and palliative management strategies. (HEPATOLOGY 2017;65:217-224).P atients with cirrhosis can experience sudden deteriorations in health that lead to increased morbidity, repeated hospitalizations, and mortality. (1)(2)(3) Hospitalization is a marker for a variety of poor outcomes including readmission and death. Although we are gaining a better understanding of risk factors for readmission in discharged patients, (1,(4)(5)(6) we lack a practical prognostic model to identify those at highest risk for 3-month postdischarge mortality.Identifying this group would facilitate interventions that include more intensive follow-up and consideration of early liver transplant when available. Moreover, an estimation of the probability of survival can help to inform the type of integrated palliative support that is provided to patients.To date, mortality prediction in patients with cirrhosis has been predominated by liver-specific and kidney-specific prognostic indicators such as the Abbreviations: AUC, area under the receiver operating characteristic curve; CI, confidence interval; HE, hepatic encephalopathy; KAM, KPS, age, MELD (model); KPS, Karnofsky Performance Status; MELD, Model for End-Stage Liver Disease; OR, odd...

NACSELD acute‐on‐chronic liver failure (NACSELD‐ACLF) score predicts 30‐day survival in hospitalized patients with cirrhosis

“…(19) However, there are factors other than age, such as sarcopenia and functional status, that likely play an additional role in determining prognosis. (20) We previously showed that hepatic encephalopathy independently impairs prognosis (21) ; however, more work needs to be done to determine the interaction between age, ACLF, and short-term and long-term outcomes. In addition, it would have been ideal to reevaluate patients for ACLF 3-5 days after diagnosis to determine if this better predicted mortality, as some have shown previously; however, these data were not available.…”

“…Increasing age also negatively impacts survival in post‐surgery ACLF . However, there are factors other than age, such as sarcopenia and functional status, that likely play an additional role in determining prognosis . We previously showed that hepatic encephalopathy independently impairs prognosis; however, more work needs to be done to determine the interaction between age, ACLF, and short‐term and long‐term outcomes.…”

Report from the American Society of Transplantation on frailty in solid organ transplantation

“…53 Frailty has consistently been shown to be a critical determinant of liver transplant outcomes, including hospitalizations, and mortality both before 2,52,54-57 and after liver transplantation. 53,[58][59][60][61] A range of tools to measure frailty and physical function have been studied in this population, and recent efforts to standardize frailty measurement in liver transplantation have yielded the Liver 2. Frailty measurements should be standardized and performed routinely in patients undergoing evaluation for liver transplantation.…”

Approaches for patients with very high MELD scores

“…105,106 A Karnofsky performance status-based score has recently been proposed for the prediction of death after hospital discharge in cirrhosis. 107 The subgroup of patients with low MELD scores and high frailty may derive the greatest benefit from implementation of these measures. 102 However, functional tests evaluating frailty could be not enough discriminant in the homogeneous population of very high MELD patients.…”