Association of liver fibrosis FIB-4 score with perioperative complications and mortality: a retrospective multicenter analysis

Shira Zelber-Sagi; Vikas N O'Reilly-Shah; Ashish K Khanna; Peter Rock; Itay Bentov; MPOG PCRC Collaborative Authors^^

doi:10.1097/ALN.0000000000005830

Association of liver fibrosis FIB-4 score with perioperative complications and mortality: a retrospective multicenter analysis

Anesthesiology. 2025 Nov 5. doi: 10.1097/ALN.0000000000005830. Online ahead of print.

Authors

Shira Zelber-Sagi¹, Vikas N O'Reilly-Shah², Ashish K Khanna^{3

4}, Peter Rock⁵, Itay Bentov²; MPOG PCRC Collaborative Authors^^

Affiliations

¹ School of Public Health, University of Haifa, 3498838 Haifa, Israel. szelber-s@univ.haifa.ac.il.
² Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA. voreill@uw.edu.
³ Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC.
⁴ Outcomes Research Consortium, Houston, TX. akhanna@wakehealth.edu.
⁵ Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD. prock@som.umaryland.edu.

PMID: 41191454
DOI: 10.1097/ALN.0000000000005830

Abstract

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) and related advanced fibrosis are associated with poor hepatic and extrahepatic outcomes. However, the role of liver fibrosis in surgery-related mortality remains unclear. We aimed to assess the association between a widely used liver fibrosis marker, the Fibrosis-4 (FIB-4) score, and 30-day postoperative mortality and complications.

Methods: A multicenter historical cohort of patients undergoing general anesthesia. Data were obtained from the Multicenter Perioperative Outcomes Group (MPOG) dataset. Exclusion criteria included known liver diseases other than MASLD, hepatic failure, and alcohol use disorder. Risk of liver fibrosis was calculated using the FIB-4 score and categorized using the MASLD accepted predefined ranges. Mixed-effects multivariable logistic regression models were built to assess the adjusted conditional odds ratio (cOR) for the primary outcome of mortality and secondary outcomes of acute kidney injury, myocardial injury, and postoperative pulmonary complications.

Results: The final cohort size for the primary outcome of mortality was 1,325,102. Compared to the low-risk FIB-4 category (≤1.3), the inconclusive FIB-4 category (1.3-2.67) was associated with an adjusted cOR of 1.533-fold for mortality [99.75% CI 1.453-1.616], while the elevated category (FIB-4≥2.67) was associated with an adjusted cOR of 3.765-fold [99.75% CI 3.572-3.969]. This association persisted with the application of age-adjusted FIB-4 cut-offs in stratification by age category. A dose-response association was also observed between FIB-4 as a continuous variable and mortality. Amongst secondary outcomes, elevated FIB-4 was associated with a postoperative cOR of 1.515 for acute kidney injury [99.75% CI 1.435-1.598], a cOR of 1.657 for myocardial injury [99.75% CI 1.401-1.960], and a cOR 1.323 for postoperative pulmonary complications [99.75% CI 1.280-1.369].

Conclusions: The FIB-4 score is associated with postoperative mortality and complications in a population without clinically apparent liver disease and evaluation may have value in preoperative patient counseling and optimization.