Authors: Zelber-Sagi S et al.
Anesthesiology. November 05, 2025. DOI: 10.1097/ALN.0000000000005830
Summary:
This large multicenter retrospective cohort study examined whether the Fibrosis-4 (FIB-4) liver fibrosis score, a simple and widely used noninvasive index, is associated with postoperative mortality and complications among surgical patients without known liver disease. Data were derived from the MPOG (Multicenter Perioperative Outcomes Group) database and included over 1.3 million patients undergoing surgery with general anesthesia.
Patients with non-MASLD liver disease, hepatic failure, or alcohol use disorder were excluded to isolate the effect of metabolic-associated steatotic liver disease (MASLD)–related fibrosis risk. FIB-4 scores were categorized into low (≤1.3), indeterminate (1.3–2.67), and high (≥2.67) fibrosis risk based on MASLD guidelines. The primary outcome was 30-day postoperative mortality, with secondary outcomes of postoperative acute kidney injury (AKI), myocardial injury, and pulmonary complications.
Compared to the low-risk group, patients in the indeterminate FIB-4 category had a 1.533-fold higher adjusted conditional odds of 30-day mortality, while those in the high-risk category had a 3.765-fold higher risk. These associations remained robust even after applying age-adjusted FIB-4 thresholds and across different age subgroups. A dose-response relationship was also demonstrated when analyzing FIB-4 as a continuous variable, supporting a strong graded association between fibrosis burden and mortality risk.
For secondary outcomes, elevated FIB-4 was significantly associated with higher adjusted odds of major postoperative complications, including AKI (cOR 1.515), myocardial injury (cOR 1.657), and postoperative pulmonary complications (cOR 1.323). These results suggest that even in the absence of known chronic liver disease, underlying subclinical fibrosis risk—reflected by FIB-4—has meaningful perioperative implications.
The authors conclude that integrating FIB-4 assessment into routine preoperative evaluation may enhance risk stratification, support patient counseling, and identify patients who might benefit from optimization before major surgery.
What You Should Know
• The FIB-4 fibrosis score strongly predicts 30-day postoperative mortality, even in patients without known liver disease.
• High FIB-4 scores (≥2.67) are associated with nearly 4-fold higher adjusted odds of postoperative death.
• Elevated FIB-4 is also linked to increased rates of AKI, myocardial injury, and pulmonary complications.
• The association remains consistent across different age groups and when using age-adjusted cutoffs.
• FIB-4 demonstrates a clear dose-response relationship with postoperative risk.
• Routine preoperative FIB-4 calculation may help identify high-risk patients who otherwise appear clinically well.
Key Points
• FIB-4 is a powerful, noninvasive predictor of postoperative mortality in over 1.3 million surgical patients.
• Even intermediate fibrosis risk (FIB-4 1.3–2.67) significantly increases perioperative mortality.
• High-risk FIB-4 (≥2.67) is associated with markedly elevated risks of AKI, myocardial injury, and pulmonary complications.
• The association persists after age adjustment, supporting its reliability across demographic groups.
• FIB-4 may serve as an effective addition to routine preoperative evaluation for improving patient optimization.
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