With a rising burden of
cirrhosis surgeries, understanding risk factors for postoperative mortality is more salient than ever. The role of baseline
frailty has not been assessed in this context. We evaluated the association between patient
frailty and postoperative risk among diverse patients with
cirrhosis and determined if
frailty improves prognostication of
cirrhosis surgical risk scores. This was a retrospective cohort study of U.S. veterans with
cirrhosis identified between 2008 and 2016 who underwent nontransplant major surgery.
Frailty was ascertained using the Hospital
Frailty Risk Score (
HFRS). Cox regression analysis was used to investigate the impact of patient
frailty on postoperative mortality. Logistic regression was used to identify incremental changes in discrimination for postoperative mortality when
frailty was added to the risk prediction models, including the Model for
End-Stage Liver Disease (MELD), MELD-
sodium (MELD-Na), Child-Turcotte-Pugh (
CTP), Mayo Risk Score (MRS), and Veterans Outcomes and Costs Associated With
Liver Disease (VOCAL)-Penn. A total of 804
cirrhosis surgeries were identified. The majority of patients (48.5%) had high-risk
frailty at baseline (
HFRS >15). In adjusted Cox regression models, categories of increasing
frailty scores were associated with poorer postoperative survival. For example, intermediate-risk
frailty (HFRS 5-15) conferred a 1.77-fold increased hazard relative to low-risk
frailty (
HFRS, <5; 95% confidence interval [CI], 1.06-2.95; P = 0.03). High-risk
frailty demonstrated a similarly increased hazard (hazard ratio, 1.74; 95% CI, 1.05-2.88; P = 0.03), suggesting a threshold effect of
frailty on postoperative mortality. The incorporation of
frailty improved discrimination of MELD, MELD-Na, and
CTP for postoperative mortality, but did not do so for the MRS or VOCAL-Penn score. Patient
frailty was an additional important predictor of
cirrhosis surgical risk. The incorporation of preoperative
frailty assessments may help to risk stratify patients, especially in settings where the MELD-Na and
CTP are commonly applied.