Applicability and prognostic value of frailty assessment tools among hospitalized patients with advanced chronic liver disease

Assessment of intestinal inflammation via fecal calprotectin for early prediction of adverse outcomes in advanced chronic liver disease

BACKGROUND AND AIMS

Intestinal inflammation assessed by fecal calprotectin (F-CAL) in advanced chronic liver disease (ACLD) may represent an early sign of intestinal barrier dysfunction. We aimed to explore the usefulness of F-CAL testing in ACLD in the prediction of adverse outcomes (AO, death, or LT) and refinement of prognostic stratification.

PATIENTS AND METHODS

We explored the RH7 cirrhosis registry comprising consecutive hospitalized patients and a control group with data on disease phenotype, demographics, anthropometrics, prognostic indices, and medication. The F-CAL was evaluated on admission and reported in multiples of the upper limit of normal or terciles. Predictive power was tested in the Cox model for AO over 180 days. Additional risk refinement by F-CAL was tested for both groups.

RESULTS

We enrolled 263 cases in the study group with a median age of 57.2 years, M/F ratio 167/96, with alcohol, metabolic dysfunction-associated steatotic liver disease, MetALD, and viral etiologies in 72.2%, 9.1, 8.0, 3.4%. The median F-CAL was 3.92 × ULN. The control group comprised 108 cases. The adjusted Cox model confirmed F-CAL (hazard ratio [HR] = 1.05, p < 0.001) and F-CAL terciles (HR = 1.413, p = 0.009) as independent predictors of AO. F-CAL terciles had higher predictive accuracy in CLIF-C-AD<50 (HR = 2.49, p = 0.013) and Child stages A and B (HR = 1.706, p = 0.025), in whom high F-CAL (cut-off >11 × ULN) could identify patients having 2-3 times higher risk of AO. This approach has been validated in the control group.

CONCLUSION

Among hospitalized patients with ACLD, F-CAL values were independently proportional to the risk of AO, particularly in early disease stages when high F-CAL values could refine prognostic stratification.

Home-based exercise and PHysical activity maintenance interventiOn after livEr traNsplantation: Impact of eXercise intensity (PHOENIX-Liver)

Liver transplant recipients experience comorbidities, including impaired physical fitness, which could be managed by exercise and physical activity interventions. This study aims to evaluate the feasibility, clinical effectiveness and cost-effectiveness of a 6-month exercise intervention, followed by a 15-month tailored physical activity maintenance intervention, in de novo liver transplant recipients. This single-centre, randomised, controlled, single-blinded trial will recruit 147 adult liver transplant recipients at 3-5 months post-transplant. Participants will be randomised into (1) 6 months of enhanced usual care, not followed by a physical activity intervention (control (CON) group, n=49), (2) 6 months of moderate-intensity exercise training, followed by a physical activity intervention (moderate-intensity training (MIT) group; n=49) or (3) consecutively 3 months of moderate-intensity exercise training, 3 months of high-intensity interval training and a physical activity intervention (moderate and high-intensity training (MHIT) group; n=49). Exercise training will consist of home-based stationary bicycling and muscle-strengthening exercises, partially supervised by participants' local physiotherapists. The physical activity intervention includes an array of behaviour change techniques. Primary hypothesis: after the exercise intervention, peak oxygen uptake (V̇O2peak) will be higher in MHIT versus CON (α-level 0.05). Secondary hypotheses: after the exercise intervention, V̇O2peak will be higher in MIT versus CON and MHIT versus MIT (α-level 0.025). Secondary outcomes, assessed up to 2 years post-transplant, include physical fitness, cardiovascular and graft health, quality of life, physical activity and implementation outcomes. Trial registration number NCT06302205.

Predictive Value of Frailty on Outcomes of Patients With Cirrhosis: Systematic Review and Meta-Analysis

Background

Frailty is one of the most common symptoms in patients with cirrhosis. Many researchers have identified it as a prognostic factor for patients with cirrhosis. However, no quantitative meta-analysis has evaluated the prognostic value of frailty in patients with cirrhosis.

Objective

This systematic review and meta-analysis aimed to assess the prognostic significance of frailty in patients with cirrhosis.

Methods

The systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations. We conducted a comprehensive search of the literature using databases such as PubMed, Cochrane Library, Embase, and Web of Science, as well as China National Knowledge Infrastructure, encompassing the period from inception to 22 December 2023. Data were extracted for frailty to predict adverse outcomes in patients with cirrhosis. RevMan (version 5.3) and R (version 4.2.2) were used to assess the extracted data.

Results

A total of 26 studies with 9597 patients with cirrhosis were included. Compared with patients having low or no frailty, the frail group had a higher mortality rate (relative ratio, RR=2.07, 95% CI 1.82-2.34, P<.001), higher readmission rate (RR=1.50, 95% CI 1.22-1.84, P<.001), and lower quality of life (RR=5.78, 95% CI 2.25-14.82, P<.001). The summary receiver operator characteristic (SROC) curve of frailty for mortality in patients with cirrhosis showed that the false positive rate (FPR) was 0.25 (95% CI 0.17-0.34), diagnostic odds ratio (DOR) was 4.17 (95% CI 2.93-5.93), sensitivity was 0.54 (95% CI 0.39-0.69), and specificity was 0.73 (95% CI 0.64-0.81). The SROC curve of readmission showed that the FPR, DOR, sensitivity, and specificity were 0.39 (95% CI 0.17-0.66), 1.38 (95% CI 0.64-2.93), 0.46 (95% CI 0.28-0.64), and 0.60 (95% CI 0.28-0.85), respectively.

Conclusions

This meta-analysis demonstrated that frailty is a reliable prognostic predictor of outcomes in patients with cirrhosis. To enhance the prognosis of patients with cirrhosis, more studies on frailty screening are required.

Waiting time dictates impact of frailty: A Spanish multicenter prospective study

BACKGROUND & AIMS

Frailty is prevalent in liver transplant (LT) candidates. It is considered an independent predictor of adverse outcomes pre- and post-transplant according to data obtained in the United States. We aimed to externally validate the liver frailty index (LFI) in a multicenter cohort of LT candidates.

METHODS

Outpatients with cirrhosis were prospectively recruited from five Spanish centers (2018-2020). Patients were defined as "frail" by an optimal cut-off of LFI ≥4.5. Patients were followed for at least 6 months to study associations of pre-LT frailty with pre- and post-transplant mortality, length of hospital and intensive care unit (ICU) stays, risk of early (<30 days) and late (30-90 days) post-transplant complications, retransplantation and cardiovascular events.

RESULTS

Of 212 patients included, 45 patients (21%) were frail pre-LT, and the median LFI was 3.9 (IQR 3.5-4.4). After a median waiting time of 78 days, 2% died or were delisted for clinical worsening. The LFI at baseline was not predictive of mortality/delisting in LT candidates in univariable or multivariable analyses after adjusting for age and MELD-Na score (hazard ratio 1.48; p = 0.586). In contrast, compared to non-frail patients, frail LT candidates had a significantly higher length of hospital stay (9 vs. 13 days; p = 0.001) and rate of early (<30 days) post-transplant complications (55% vs. 100%; p = 0.021).

CONCLUSIONS

In the context of a short LT waiting time, frailty does not impact pretransplant mortality and/or delisting. In contrast, LT frailty is predictive of higher post-transplant complication rates and length of hospital stay. Whether strategies aimed at pre- and/or re-habilitation are beneficial in settings with short waiting times needs to be confirmed in prospective studies.

IMPACT AND IMPLICATIONS

Literature is scarce on the actual impact of physical frailty on adverse outcomes in the liver transplant scenario outside North America. Evidence-based justification to extend the use of objective frailty tools in the decision-making processes in other liver transplant settings is needed. This study is the first to evaluate the predictive value of the liver frailty index in outpatients in the European liver transplant setting, showing that in a low MELD, high access system, frailty does not impact pretransplant mortality and/or delisting but is predictive of higher complication rates and longer post-transplant length of stay. In practical ways, physicians should consider physical frailty as a vital sign to be measured systematically and routinely during clinic visits; researchers are encouraged to initiate prospective studies to evaluate the benefit of applying strategies aimed at pre- and or re-habilitation in liver transplant settings with short waiting times.

Frailty as a risk-stratification tool in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS)

Objectives

The concept of frailty has gained importance, especially in patients with liver disease. Our study systematically investigated the effect of frailty on post-procedural outcomes in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS).

Methods

We used National Inpatient Sample(NIS) 2016-2019 data to identify patients who underwent TIPS. Hospital frailty risk score (HFRS) was used to classify patients as frail (HFRS>=5) and non-frail (HFRS<5). The relationship between frailty and outcomes such as death, post-procedural shock, non-home discharge, length of stay (LOS), post-procedural LOS, and total hospitalization charges (THC) was assessed.

Results

A total of 13,700 patients underwent TIPS during 2016-2019. Of them, 5,995 (43.76%) patients were frail, while 7,705 (56.24%) were non-frail. There were no significant differences between the two groups based on age, gender, race, insurance, and income. Frail patients had higher mortality (15.18% vs. 2.07%, p<0.001), a higher incidence of non-home discharge (53.38% vs. 19.08%, p<0.001), a longer overall LOS (12.5 days vs. 3.35,p<0.001), longer post-procedural stay (8.2 days vs. 3.4 days, p<0.001), and higher THC ($240,746.7 vs. $121,763.1, p<0.001) compared to the non-frail patients. On multivariate analysis, frail patients had a statistically significant higher risk of mortality (aOR-3.22, 95% CI-1.98- 5.00, p<0.001).

Conclusion

Frailty assessment can be beneficial in risk stratification in patients undergoing TIPS.

Low back pain in patients hospitalised with liver cirrhosis- a retrospective study

BACKGROUND

Lower back pain is a common issue, but little is known about the prevalence of pain in patients with liver cirrhosis during hospitalisation. Therefore, the objective of this study was to determine lower back pain in patients with liver cirrhosis.

METHODS

The sample consisted of patients with liver cirrhosis (n = 79; men n = 55; women n = 24; mean age = 55.79 ± 12.52 years). The hospitalised patients were mobile. The presence and intensity of pain were assessed in the lumbar spine during hospitalisation. The presence of pain was assessed using the visual analogue pain scale (0-10). The range of motion of the lower spine was assessed using the Schober and Stibor tests. Frailty was measured by Liver Frailty Index (LFI). The condition of liver disease was evaluated using The Model For the End-Stage Liver Disease (MELD) and Child-Pugh score (CPS) and ascites classification. Student's t test and Mann-Whitney test were used for analysis of the difference of group. Analysis of variance (ANOVA) with the Tukey post hoc test was used to test differences between categories of liver frailty index. The Kruskal-Wallis test was used to test pain distribution. Statistical significance was determined at the α-0.05 significance level.

RESULT

The prevalence of pain in patients with liver cirrhosis was 13.92% (n = 11), and the mean intensity of pain according to the visual analogue scale was 3.73 (± 1.90). Lower back pain was present in patients with ascites (15.91%; n = 7) and without ascites (11.43%; n = 4). The prevalence of lower back pain was not statistically significant between patients with and without ascites (p = 0,426). The base of Schober's assessment mean score was 3.74 cm (± 1.81), and based on Stibor's assessment mean score was 5.84 cm (± 2.23).

CONCLUSION

Lower back pain in patients with liver cirrhosis is a problem that requires attention. Restricted spinal mobility has been reported in patients with back pain, according to Stibor, compared to patients without pain. There was no difference in the incidence of pain in patients with and without ascites.

Comparison of the quality of life of patients with liver cirrhosis before and during the COVID-19 lockdown in Slovakia

Liver cirrhosis is associated with a poor quality of life (QOL). The COVID-19 pandemic has led to several restriction measures and psychosocial consequences whose impact on QOL has combined with that of cirrhosis in an unknown way. Therefore, we have used our cirrhosis registry to assess the quality of life before the pandemic (on the first admission to the tertiary liver unit) and during the most pronounced phase of the first lockdown. In this cross-sectional study conducted during the first lockdown in Slovakia (from April to May 2020), we have repeated the QOL measurement of QOL in cirrhotic patients previously enrolled in the RH7 registry. Patients who were alive (according to the national registry of deaths) were identified and contacted by phone with a structured and standardized interview led by trained professionals. The tool used for both QOL measurements (at enrolment in RH7 and during lockdown) was a standardized and validated EuroQOL-5D (EQ-5D) questionnaire. The study included 97 patients, of which 37 (38.1%) were women and 60 (61.9%) were men. Responses were achieved from 75 patients (68.18%). In general, patients scored their quality of life significantly higher during the pandemic compared to examination at admission to RH7 (that is, at admission to our tertiary liver unit with cirrhosis) (p = 0.005). In particular, of the domains included in EQ-5D: (1) self-care was better during lockdown compared to the first record on admission to RH7 (p < 0.001). (2) the ability to perform daily activities has also improved during lockdown (p = 0.002). On the other hand, (3) pain and discomfort did not change significantly during the lockdown compared to the previous measurement (p = 0.882). (4) anxiety and depression were lower during lockdown compared to admission to RH7 (p = 0.01). The quality of life in patients with liver cirrhosis was better during the lockdown of SARS-CoV-2 compared to the previous measurement at admission to the tertiary liver unit.

Systematic review: the role of frailty in advanced chronic liver disease

BACKGROUND

Frailty is a known predictor of outcome and mortality in patients undergoing liver transplantation. However, most patients remain unsuitable transplant candidates. It is not yet known if the assessment of frailty in non-transplant candidates can aid prognostication.

AIM

To collate and interrogate the various frailty tools presently used to predict mortality in the non-transplant cirrhosis setting.

METHODS

A comprehensive review of MEDLINE and EMBASE databases for articles published from inception to March 2022 was undertaken, excluding those where patients underwent transplantation or had hepatocellular carcinoma.

RESULTS

We identified 12 observational cohort studies, featuring 9 frailty indices. These were from various global healthcare settings and of fair or good quality. Most were objective tools utilising clinician-based assessments. All frailty scores predicted prognosis, with variability in the method of application, and utilisation in long- or short-term mortality. Three studies directly compared different indices in the same population. There was some evidence that simple tools could perform as well, if not better, than more complex, time-consuming scores.

CONCLUSIONS

Various frailty tools can reproducibly evaluate mortality in patients with cirrhosis who are ineligible for transplant. However, further prospective head-to-head comparative studies are needed. In addition to determining model utility, studies should focus on important relative considerations which may limit widespread implementation including, ease of use and limited resources, given the global disparity of liver care provision. These tools may positively identify specific patient cohorts at risk of impending deterioration, thereby stratifying those patients likely to benefit from early integration with palliative care.

Frailty as a predictor of poor outcomes among patients awaiting liver transplant: a systematic review and meta-analysis

Aim

This review sought to evaluate the significance of a functional assessment for liver transplant candidates, i.e., frailty, in the pre-transplant setting and its association with mortality and morbidities.

Background

Liver transplantation (LT) remains the treatment of choice for patients with end-stage liver disease. Due to the shortage of organs for LT, a careful selection of suitable recipients is essential. Frailty, a measure of physiologic reserve and increased vulnerability to stressors, was initially used in geriatrics and then introduced to the field of transplantation for better patient selection.

Methods

PubMed, Scopus, and Web of Science databases were reviewed up until January 2023. The search terms included: "frail*", "liver", and "transplant*". A Meta-analysis was conducted for the hazard ratios (HRs) obtained from the COX regression models. Fifty-five studies were included in this review; ten were included in the meta-analysis.

Results

The prevalence of frailty varied from 2.82% to 70.09% in the studies. Meta-analysis showed that overall frailty had a significant association with mortality (pooled adjusted HR [95%CI]: 2.66 [1.96-3.63]). Subgroup analyses revealed that both the Liver Frailty Index and Fried Frailty Index were significantly associated with mortality. Furthermore, these studies have demonstrated that this population's frailty is associated with ascites, hepatic encephalopathy, and esophageal varices.

Conclusion

According to emerging evidence, frailty is associated with increased morbidity and mortality of the patients on the LT waiting list. Further randomized trials are required to determine the efficacy and safety of variable interventions in the frail population.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review

Background

The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs).

Methods

An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs.

Findings

After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%).

Discussion

CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

Frailty in Nonalcoholic Fatty Liver Cirrhosis: A Comparison with Alcoholic Cirrhosis, Risk Patterns, and Impact on Prognosis

BACKGROUND

Physical frailty increases susceptibility to stressors and predicts adverse outcomes of cirrhosis. Data on disease course in different etiologies are scarce, so we aimed to compare the prevalence and risk factors of frailty and its impact on prognosis in nonalcoholic fatty liver (NAFLD) and alcoholic (ALD) cirrhosis. Patients and Methods. Cirrhosis registry RH7 operates since 2014 and includes hospitalized patients with decompensated cirrhosis, pre-LT evaluation, or curable hepatocellular carcinoma (HCC). From the RH7, we identified 280 ALD and 105 NAFLD patients with at least 6 months of follow-up.

RESULTS

Patients with NAFLD compared with ALD were older and had a higher proportion of females, higher body mass index (BMI) and mid-arm circumference (MAC), lower MELD score, CRP, and lower proportion of refractory ascites. The liver frailty index did not differ, and the prevalence of HCC was higher (17.1 vs. 6.8%, p=0.002). Age, sex, serum albumin, and C-reactive protein (CRP) were independent predictors of frailty. In NAFLD, frailty was also associated with BMI and MAC and in ALD, with the MELD score. The Cox model adjusted for age, sex, MELD, CRP, HCC, and LFI showed that NAFLD patients had higher all-cause mortality (HR = 1.88 95% CI 1.32-2.67, p < 0.001) and were more sensitive to the increase in LFI (HR = 1.51, 95% CI 1.05-2.2).

CONCLUSION

Patients with NAFLD cirrhosis had a comparable prevalence of frailty compared to ALD. Although prognostic indices showed less advanced disease, NAFLD patients were more sensitive to frailty, which reflected their higher overall disease burden and led to higher all-cause mortality.