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Risk Prediction Models for Postoperative Decompensation and Infection in Patients With Cirrhosis: A Veterans Affairs Cohort Study

  • Nadim Mahmud
    Correspondence
    Reprint requests Address requests for reprints to: Nadim Mahmud, MD, MS, MPH, MSCE, 3400 Civic Center Blvd, 4th Fl, South Pavilion, Philadelphia, Pennsylvania 19104. phone: (215) 349-8222; fax: (215) 349-5915.
    Affiliations
    Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania

    Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania

    Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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  • Zachary Fricker
    Affiliations
    Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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  • James D. Lewis
    Affiliations
    Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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  • Tamar H. Taddei
    Affiliations
    Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut

    VA Connecticut Healthcare System, West Haven, Connecticut
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  • David S. Goldberg
    Affiliations
    Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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  • David E. Kaplan
    Affiliations
    Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

    Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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      Background and Aims

      Patients with cirrhosis have an increased risk of postoperative mortality for a range of surgeries; however, they are also at risk of postoperative complications such as infection and cirrhosis decompensation. To date, there are no prediction scores that specifically risk stratify patients for these morbidities.

      Methods

      This was a retrospective study using data of patients with cirrhosis who underwent diverse surgeries in the Veterans Health Administration. Validated algorithms and/or manual adjudication were used to ascertain postoperative decompensation and postoperative infection through 90 days. Multivariable logistic regression was used to evaluate prediction models in derivation and validation sets using variables from the recently-published Veterans Outcomes and Costs Associated with Liver Disease (VOCAL)-Penn cirrhosis surgical risk scores for postoperative mortality. Models were compared with the Mayo risk score, Model for End-stage Liver Disease (MELD)-sodium, and Child-Turcotte-Pugh (CTP) scores.

      Results

      A total 4712 surgeries were included; patients were predominantly male (97.2 %), white (63.3 %), and with alcohol-related liver disease (35.3 %). Through 90 postoperative days, 8.7 % of patients experienced interval decompensation, and 4.5 % infection. Novel VOCAL-Penn prediction models for decompensation demonstrated good discrimination for interval decompensation (C-statistic 0.762 vs 0.663 Mayo vs 0.603 MELD-sodium vs 0.560 CTP; P < .001); however, discrimination was only fair for postoperative infection (C-statistic 0.666 vs 0.592 Mayo [P = .13] vs 0.502 MELD-sodium [P < .001] vs 0.503 CTP [P < .001]). The model for interval decompensation had excellent calibration in both derivation and validation sets.

      Conclusion

      We report the derivation and internal validation of a novel, parsimonious prediction model for postoperative decompensation in patients with cirrhosis. This score demonstrated superior discrimination and calibration as compared with existing clinical standards, and will be available at www.vocalpennscore.com.

      Keywords

      Abbreviations used in this paper:

      ALD (Alcohol-related liver disease), ASA (American Society of Anesthesiologists), BMI (body mass index), CI (confidence interval), CTP (Child-Turcotte-Pugh), HCV (hepatitis C virus), IQR (interquartile range), MELD-Na (Model for End-stage Liver Disease-Sodium), NAFLD (non-alcoholic fatty liver disease), TIPS (transjugular intrahepatic portosystemic shunt), VASQIP (Veterans Affairs Surgical Quality Improvement Program), VHA (Veterans Health Administration), VOCAL (Veterans Outcomes and Costs Associated with Liver Disease)
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