Hepatic encephalopathy impacts the predictive value of the Fried Frailty Index

Abstract

Frailty is increasingly recognized as a predictor of poor outcomes in solid organ transplantation. The most widely utilized frailty tool, the Fried Frailty Index (FFI), includes patient-reported exhaustion, weight loss, and physical activity as well as measured walk speed and handgrip. Although hepatic encephalopathy (HE) is common among liver transplant candidates, data are lacking regarding its impact on the interpretation of frailty. We prospectively enrolled 685 patients with cirrhosis during their transplant evaluation, following them until death or transplantation. Our cohort was aged 54.5 ± 10.3 years, 60% male, with an average MELD score of 14.7 ± 6.3. A history of HE was present in 39%. Frailty was present in 41%, associated with higher MELD, low albumin, ascites, and HE. HE was associated with frail performance on three components of the FFI-grip (odds ratio 1.41 95% CI, 1.03-1.92), walk speed (1.56 95% CI, 1.14-2.15), and decreased energy (1.44 95% CI, 1.05-1.99). These three components were associated with transplant free survival in the whole cohort: energy (hazard ratio 1.67 95% CI, 1.25-2.28), grip (1.63 95% CI, 1.24-2.16), and walk speed (1.56 95% CI, 1.19-2.04). However, among patients with HE, the FFI was not associated with survival. HE plays a critical role in the frailty phenotype and the implications of frailty among patients with cirrhosis evaluated for liver transplantation.

Keywords: cirrhosis; clinical research/practice; health services and outcomes research; liver transplantation/hepatology; patient survival.

Figure 1:. Frailty is Not Predictive of Transplant-Free Survival in Patients with Hepatic Encephalopathy

Figure 1 delineates the association of frailty with transplant-free survival in patients without (panel A) and with (panel B) hepatic encephalopathy. While 3 components of the Fried Frailty Index are significantly predictive of survival in patients without encephalopathy, none are for patients with encephalopathy. Hazard ratios are presented with 95% confidence intervals (CI) with a dashed-line to indicate 1.0; intervals that cross 1.0 are not significant. All estimates are adjusted for Model for Endstage Liver Disease Score, albumin concentration, and the presence of ascites.