Authors: Zelber-Sagi S et al.
Journal: Anesthesiology, December 12, 2025. DOI: 10.1097/ALN.0000000000005830
Summary
This large multicenter retrospective analysis evaluated whether the Fibrosis-4 (FIB-4) score—an inexpensive, routinely available marker of liver fibrosis—is associated with perioperative mortality and complications in patients undergoing general anesthesia who did not have clinically apparent liver disease. Given the high prevalence of metabolic dysfunction–associated steatotic liver disease (MASLD), the study sought to clarify whether subclinical liver fibrosis confers independent perioperative risk.
Using data from more than 1.3 million patients in the Multicenter Perioperative Outcomes Group database, patients were stratified into low, indeterminate, and high-risk fibrosis categories based on established FIB-4 thresholds. After adjustment for demographic, clinical, and procedural factors, increasing FIB-4 score was strongly and independently associated with higher 30-day postoperative mortality. Patients in the indeterminate fibrosis range had a roughly 50% increase in adjusted mortality risk, while those in the high FIB-4 category had nearly a fourfold increase compared with low-risk patients. These associations were consistent across age-stratified cutoffs and demonstrated a clear dose–response relationship when FIB-4 was analyzed as a continuous variable.
Higher FIB-4 scores were also associated with increased odds of major postoperative complications, including acute kidney injury, myocardial injury, and postoperative pulmonary complications. Importantly, these findings were observed in patients without diagnosed chronic liver disease, suggesting that occult fibrosis represents a clinically meaningful marker of systemic vulnerability rather than isolated hepatic pathology.
Overall, the study demonstrates that FIB-4 captures perioperative risk not otherwise apparent during routine preoperative assessment and may serve as a practical tool for risk stratification, counseling, and perioperative optimization in surgical patients.
Key Points
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Higher FIB-4 scores are strongly associated with increased 30-day postoperative mortality.
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Patients with elevated FIB-4 had nearly fourfold higher adjusted mortality risk.
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A clear dose–response relationship exists between FIB-4 and mortality.
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Elevated FIB-4 is associated with higher rates of acute kidney injury, myocardial injury, and pulmonary complications.
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Findings apply to patients without clinically recognized liver disease.
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FIB-4 may be a useful, low-cost preoperative risk stratification tool.
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