Development of a Novel Frailty Index to Predict Mortality in Patients With End-Stage Liver Disease
Development of a Novel Frailty Index to Predict Mortality in Patients With End-Stage Liver Disease
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DOI：
10.1002/hep.29219
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发表时间：
2017-08-01
期刊：
影响因子：
13.5
通讯作者：
Feng, Sandy
中科院分区：
文献类型：
--
作者：
Lai, Jennifer C.;Covinsky, Kenneth E.;Feng, Sandy
肝硬化的特点是肌肉萎缩、营养不良和功能衰退，导致死亡率过高，而终末期肝病模型 (MELD) 钠 (MELDNa) 评分无法很好地量化死亡率。我们的目的是开发一个虚弱指数来捕获肝硬化的这些肝外并发症并增强肝硬化患者的死亡率预测。使用候选虚弱指标对在单一移植中心连续列出进行肝移植且无 MELD 例外情况的门诊患者进行评估。使用 Cox 回归进行的最佳子集选择分析确定了预测等候名单死亡率（=因病死亡或除名）的虚弱测量子集。我们通过平衡统计准确性和临床实用性来选择衰弱指数。净重分类指数 (NRI) 通过将衰弱指数添加到 MELDNa 来评估正确重分类的患者百分比。其中包括 536 名肝硬化患者，MELDNa 中位数为 18。其中 107 名 (20%) 患者死亡/被除名。最终的虚弱指数包括：握力、椅子站立和平衡。 MELDNa 和虚弱指数根据 3 个月候补名单死亡风险（即一致性统计）正确对患者进行排名的能力分别为 0.80 和 0.76，但 MELDNa+虚弱指数合计为 0.82。与单独使用 MELDNa 相比，MELDNa+虚弱指数正确地重新分类了 16% 的死亡/除名 (P = 0.005) 和 3% 的非死亡/除名 (P 5 0.17)，总 NRI 为 19% (P < 0.001)。与虚弱指数得分较高的人（第 80 个百分位数）相比，步态速度、日常生活工具性活动困难、疲惫和体力活动量低等因素对他们的损害更大（每项 P < 0.001）。结论：我们的肝硬化患者虚弱指数由三个基于表现的指标组成，与单独使用 MELDNa 相比，构建了虚弱概念的有效性，并改善了等待名单死亡率的风险预测。
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 5 0.17) with a total NRI of 19% (P < 0.001). Compared to those with robust 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.