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International Normalized Ratio (INR) Is Comparable to MELD in Predicting Mortality after Cholecystectomy
Abstract:
Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1, 80.4 per cent had INR > 1 to ≤1.5, 3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension (P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10-2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97-4.45]), and INR > 2 (OR = 3.21 [1.64-6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.
Insights
Preoperative international normalized ratio (INR) predicts mortality and bleeding after cholecystectomy, comparable to MELD scores. Higher INR levels correlate with increased postoperative risks.
Area of Science:
- Hepatology
- Surgical Outcomes
- Medical Informatics
Background:
- Current guidelines recommend a preoperative international normalized ratio (INR) below 1.5 for surgical procedures.
- The predictive value of INR for postoperative outcomes in cholecystectomy patients requires further investigation relative to established scoring systems like MELD.
Purpose of the Study:
- To compare the predictive capability of preoperative INR with the Model for End-Stage Liver Disease (MELD) score for 30-day postoperative mortality and bleeding risk in cholecystectomy patients.
- To evaluate the association between different preoperative INR ranges and adverse postoperative outcomes.
Main Methods:
- Retrospective analysis of adult patients undergoing open or laparoscopic cholecystectomy from the American College of Surgeons NSQIP database (2005-2016).
- Patients were stratified into INR groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2.
- Multivariable logistic regression models were used to assess the association between INR and 30-day postoperative mortality, controlling for baseline characteristics.
Main Results:
- A total of 58,177 patients were analyzed. The majority (80.4%) had an INR between >1 and ≤1.5.
- A stepwise increase in 30-day mortality was observed with higher INR levels: OR 1.50 for INR >1 to ≤1.5, OR 2.96 for INR >1.5 to ≤2, and OR 3.21 for INR >2, all relative to INR ≤1.
- The C-statistic indicated similar predictive performance for INR (0.910) and MELD (0.906) in mortality prediction. Increased bleeding risk was also associated with higher INR groups.
Conclusions:
- Preoperative INR is a significant predictor of 30-day postoperative mortality and bleeding risk following cholecystectomy.
- The predictive accuracy of INR for these outcomes is comparable to the MELD score.
- These findings support the continued use of INR as a valuable preoperative risk assessment tool in cholecystectomy patients.
