Aim: Is Karnofsky Performance Status (KPS) a predictor of 3 month post discharge mortality in cirrhotic patients?
Background: Cirrhotic patients often experience an abrupt decline in their health, which often leads to frequent hospitalization and
can cause morbidity and mortality. Various models are currently used to predict mortality in cirrhotics however these have their
limitations. The Karnofsky Performance Status (KPS) being one of the oldest performance status scales, is a health care provider–
administered assessment that has been validated to predict mortality across the elderly and in the chronic disease populations.
Methods: We used the KPS performance status scale to envisage short-term mortality in cirrhotic and HCC patients who survive to
be discharged from hospital.
Results: Our study showed that KPS one week post-discharge, child pugh score, hospital stay, international normalized ratio, serum
albumin, total bilirubin and serum creatinine showed statistical significance on univariate analysis. On multivariate analysis, KPS was
found to be statistical significant predictor of 3-month mortality.
Conclusion: Hence KPS can be utilized to identify cirrhotic patients at risk of 3-month post discharge mortality.
Keywords: Karnofsky Performance Status (KPS), Cirrhosis, 3 months mortality
(Please cite as: Khalid MA, Achakzai IK, Ahmed Khan S, Majid Z, Hanif FM, Iqbal J, et al. The use of Karnofsky
Performance Status (KPS) as a predictor of 3 month post discharge mortality in cirrhotic patients Gastroenterol
Hepatol Bed Bench 2018;11(4):301-305).
1 Hospitalization is a marker of poor outcomes
including readmission and death. Patients with cirrhosis
experience abrupt deterioration in their health that leads
to repeated hospitalizations along with increased
morbidity and mortality (1-3). Currently, the models
used to predict mortality in cirrhotics are liver-specific
and kidney-specific prognostic indicators such as the
Model for End-Stage Liver Disease (MELD) score (4).
However the MELD score has several limitations (5-7)
one of them being its lack of ability to account for an
individual’s performance status.
It is now a well-known fact that performance status and
the linked concept of infirmity are strong predictors of
Bajaj JS, Reddy KR, Tandon P, Wong F, Kamath PS, Garcia- Tsao G, et al. The three-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. HEPATOLOGY 2016;64:200-208.
Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013;144:1426-1437
Cordoba J, Ventura-Cots M, Simon-Talero M, Amoros A, Pavesi M, Vilstrup H, et al. Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute-on-chronic liver failure (ACLF). J Hepatol 2014;60:275-281.
Kamath PS, Wiesner RH, Malinchoc M, Kremers W, TherneauTM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease. HEPATOLOGY 2001;33:464-470.
Huo TI, Lee SD, Lin HC. Selecting an optimal prognostic systemfor liver cirrhosis: the model for end-stage liver disease and beyond. Liver Int 2008;28:606-613.
Bambha KM, Biggins SW. Inequities of the Model for End- Stage Liver Disease: an examination of current components and future additions. Curr Opin Organ Transplant 2008;13:227-233.
Biggins SW, Bambha K. MELD-based liver allocation: who is underserved? Semin Liver Dis 2006;26:211-220.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-M156.
Rockwood K, Howlett SE, MacKnight C, Beattie BL, Bergman H, Hebert R, et al. Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian Study of Health and Aging. J Gerontol A Biol Sci Med Sci 2004;59:1310-1317.
Afilalo J, Karunananthan S, Eisenberg MJ, Alexander KP, Bergman H. Role of frailty in patients with cardiovascular disease. Am J Cardiol 2009;103:1616-1621.
Uchmanowicz I, Loboz-Rudnicka M, Szelag P, Jankowska- Polanska B, Loboz-Grudzien K. Frailty in heart failure. Curr Heart Fail Rep 2014;11:266-273.
Johansen KL, Chertow GM, Jin C, Kutner NG. Significance of frailty among dialysis patients. J Am Soc Nephrol 2007;18: 2960-2967.
Park SK, Richardson CR, Holleman RG, Larson JL. Frailty in people with COPD, using the National Health and Nutrition Evaluation Survey dataset (2003-2006). Heart Lung 2013;42: 163-170.
Kahlon S, Pederson J, Majumdar SR, Belga S, Lau D, Fradette M, et al. Association between frailty and 30-day outcomes after discharge from hospital. CMAJ 2015;187:799-804.
Tapper EB, Finkelstein D, Mittleman MA, Piatkowski G, Lai M. Standard assessments of frailty are validated predictors of mortality in hospitalized patients with cirrhosis. HEPATOLOGY 2015;62:584-590.
Orman ES, Ghabril M, Chalasani N. Poor performance status is ssociated with increased mortality in patients with cirrhosis. Clin Gastroenterol Hepatol 2016;14:1189-1195. )
Lai JC, Feng S, Terrault NA, Lizaola B, Hayssen H, Covinsky K. Frailty predicts waitlist mortality in liver transplant candidates Am J Transplant 2014;14:1870-1879.
Tandon P, Tangri N, Thomas L, Zenith L, Shaikh T, Carbonneau M, et al. A rapid bedside screen to predict unplanned hospitalization and death in outpatients with cirrhosis: a prospective evaluation of the Clinical Frailty Scale. Am J Gastroenterol 2016; doi:10.1038/ajg.2016.303.
Mitnitski AB, Graham JE, Mogilner AJ, Rockwood K. Frailty, fitness and late-life mortality in relation to chronological and biological age. BMC Geriatr 2002;2:1.
Zimmermann C, Burman D, Bandukwala S, Seccareccia D, Kaya E, Bryson J, et al. Nurse and physician inter-rater agreement of three performance status measures in palliative care outpatients.
Support Care Cancer 2010;18:609-616.
Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed. Evaluatio of Chemotherapeutic Agents in Cancer. New York: Columbia University Press; 1949:191-205.
van Diepen M, Schroijen MA, Dekkers OM, Rotmans JI, Krediet RT, Boeschoten EW, et al. Predicting mortality in patients with diabetes starting dialysis. PLoS One 2014;9: e89744
Brezinski D, Stone PH, Muller JE, Tofler GH, Davis V, Parker C, et al. Prognostic significance of the Karnofsky Performance Status score in patients with acute myocardial infarction: comparison with the left ventricular ejection fraction and the exercise treadmill test performance. The MILIS Study Group. Am Heart J 1991;121:1374-1381.
Crooks V, Waller S, Smith T, Hahn TJ. The use of the Karnofsky Performance Scale in determining outcomes and risk in geriatric outpatients. J Gerontol 1991;46:M139-M144.
Schag CC, Heinrich RL, Ganz PA. Karnofsky performance statu revisited: reliability, validity, and guidelines. J Clin Oncol 1984;2:187-193.
Mor V, Laliberte L, Morris JN, Wiemann M. The Karnofsk Performance Status scale. An examination of its reliability and validity in a research setting. Cancer 1984;53:2002-2007.
Bajaj JS, O’Leary JG, Reddy KR, Wong F, Olson JC, Subramanian RM, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) experience. HEPATOLOGY 2012;56:2328-2335.
Puneeta Tandon, K. Rajender Reddy, A Karnofsky Performance Status–Based Score Predicts Death After Hospital Discharge in Patients With Cirrhosis HEPATOLOGY 2017;65:217-224.
Zisberg A, Shadmi E, Gur-Yaish N, Tonkikh O, Sinoff G.Hospital-associated functional decline: the role of hospitalizationprocesses beyond individual risk factors. J Am Geriatr Soc 2015;63:55-62.
Kanwal F, Asch SM, Kramer JR, Cao Y, Asrani S, El-Serag HB. Early outpatient follow-up and 30-day outcomes in patients hospitalized with cirrhosis. HEPATOLOGY 2016;64:569-581.