ABSTRACT
Background: MELD and Child-Pugh scores have traditionally been used as prognostic indicators in patients with cirrhosis. Albumin infusions in outpatients have been associated with improved outcomes, but not in transplant waitlisted patients or inpatients. This aim of this study was to assess whether low serum albumin (sAlb) on admission alone is a poor prognostic indicator among cirrhotic inpatients from a new multi-national cohort. Method(s): The CLEARED study is a global study that enrolled consecutive non-electively admitted inpatients without organ transplant or COVID-19 from 6 continents. Admission demographics, medical history, laboratory data, inpatient course, death/hospice transfer and mortality at 30 days post-discharge were recorded. Patients were divided into 3 groups: sAlb <28gm/L(A), sAlb >=28 but <35gm/L (B), and sAlb>=35gm/L (C) were compared. Multi-variable logistic regression was performed using inpatient mortality and overall 30-day mortality as outcomes. Result(s): 2429 patients were enrolled from 21 countries worldwide. The distribution was A:49%, B:39%, C:12%. Gp A patients were significantly younger (54yrs vs. 57yrs vs 58yrs p<0.0001) but with similar gender distribution, and higher MELD-Na score of 25 vs. 20 vs. 17 (p<0.0001). Gp A patients were more likely to have alcohol as etiology of cirrhosis (49% vs. 45% vs 38%, p=0.004), and were more likely to have either infection (27% vs. 18% vs. 13%, p<0.0001), HE (39% vs. 33% vs. 23%, p=0.005) or fluid related issues as a reason for admission (p<0.0001). More patients in Gp A received albumin infusion during their hospital stay (120gm vs. 100gm vs. 100gm p=0.0004), mostly for the indications of AKI (47% vs. 49% vs. 47%, p=0.79) and performance of large volume paracentesis (44% vs. 42% vs. 41%, p=0.80), followed by bacterial peritonitis indication (22% vs. 17% vs. 11%, p=0.01). Group A patients had longer hospital stays (9 days vs. 8 days vs. 7 days (p<0.001), but similar ICU transfer (23% vs. 22% vs. 20%, p=0.55). group A patients were more likely to die while inpatients (19% vs. 11% vs. 5%, p<0.0001), or by 30 days post-discharge (29% vs. 20% vs. 9%, p<0.0001). Table shows the admission variables associated with a poor outcome. Conclusion(s): Hypoalbuminemia is extremely common among admitted cirrhotic patients, with sAlb of <28gm/L occurring in almost half. Together with MELD-Na score and infection at admission, a low sAlb is associated with a poor outcome in these patients. Future studies will need to validate these findings and to assess whether albumin infusions will improve the outcome of these patients. (Figure Presented).
ABSTRACT
Background: Although cirrhosis is a major cause of mortality worldwide, there could be disparities in outcomes. This needs a global consortium to study disparities in inpatient cirrhosis care Aim: Define the impact of location in prediction of outcomes in inpts with cirrhosis. Method(s): CLEARED prospectively enrolled non-electively admitted cirrhosis pts without COVID from all continents. To ensure equity, we allowed only 50 pts/site. Admission details, cirrhosis history, inpatient & 30-day course were recorded. World bank classification of low/low middle income (LMI), upper middle (UMI) & High income (HI) were used. Cirrhosis details, inpatient & 30-day outcomes were compared between groups. Multi-variable regression was performed using inpatient & 30-day mortality as outcomes. Result(s): 2758 pts from 21 countries from all continents, including Africa & Australia, were included.727 were L/LMI, 1050 UMI & 981 pts were from HICs. More men & younger pts were in LMI. Cirrhosis details: More pts in HI gp had 6M hospitalizations & infections, HE & ascites while prior variceal bleeding was higher in LMI . Prior HCC & transplant listings were lower in LMI but similar in UMI/HI. Alcohol & NASH was highest in HI. Viral hepatitis & cryptogenic were highest in UMI.Admissions: Admission MELD was highest in LMI. LMI pts were admitted more for GI Bleed, HE, & DILI, while anasarca & HBV flares were higher in UMI. Higher SBP (36% vs 24% vs 21% p<0.0001) & lowest skin/soft-tissue infections were in LMI (5% vs 5% vs 10% p=0.008);rest were similar. Nosocomial infections, driven by UTI were highest in LMI & HI pts (15% vs 14% vs 11% UMI, p=0.03). Admission diuretics, PPIs, Lactulose & statins were highest & antivirals lower in HI. SBP prophylaxis & rifaximin were highest in LMI pts. Outcome(s): More LMI pts needed ICU & had more organ failures (Fig B). Discharge MELD was highest in LMI. In-hospital mortality was highest & transplant lowest in LMI. This extended to 30-day mortality & transplant in LMI patients vs HI pts.Regression: In-hospital mortality was linked with age, infections, MELD & being in a LMI/UMI vs HIC while being on a transplant list, diabetes, & SBP prophylaxis were protective (Fig C). 30-day mortality predicted by age, ascites, HCC, discharge MELD, organ failures, LMI/UMI vs HIC but rifaximin was protective(Fig D). In-hospital transplant was higher with high MELD, admission rifaximin & listed pts &lower in LMI (OR 0.26) & UMI (OR 0.22) & age. 30-day transplant was higher in those with hyponatremia, ascites & HRS, on the list & on rifaximin and lower in LMI (OR 0.24) & UMI (OR 0.59) vs HI. Conclusion(s): In a global study of inpatients with cirrhosis, there were major differences in outcomes. Not being in a high-income country significantly increased the risk of inpatient and 30-day mortality independent of demographics, medications, in-hospital course, and cirrhosis severity likely due to disparities in access to transplant, which should be accounted for in global models. (Figure Presented).
ABSTRACT
Background and aims: A global study with equitable participation for cirrhosis and chronic liver disease (CLD) outcomes is needed. We initiated the Chronic Liver disease Evolution And Registry for Events and Decompensation (CLEARED) study to provide this global perspective. Aim to evaluate determinants of inpatient mortality and organ dysfunction in a multi-center worldwide study. Method: We prospectively enrolled pts with CLD/Cirrhosis >18 years without organ transplant or COVID-19 who were admitted non-electively. To maintain equity in outcome analysis, a maximum of 50 pts/site were allowed. Data for admission variables, hospital course, and inpatient outcomes (ICU, death, organ dysfunction [ODF]) were recorded. This was analyzed for death and ODs using significant variables on admission and including World Bank classification of low/middle-income countries (LMIC). A model for in-hospital mortality for all variables during the hospital course, including ODs) was analyzed. Results: 1383 pts (55 ± 13 yrs, 64% men, 39% White, 30% Asian, 10% Hispanic, 9% Black, 12% other) were enrolled from 49 centers (Fig A). 39% were from high-income while the rest were from LMICs. Admission MELDNa 23 (6–40) with history in past 6 months of hospitalizations 51%, infections 25%, HE 32%, AKI 23%, prior LVP 15%, hydrothorax 8% and HCC 4%. Leading etiologies were Alcohol 46% then NASH 23%, HCV 11% and HBV 13%. Most were on lactulose 52%, diuretics 53%, PPI 49% and statins 11%, SBP prophylaxis 16%, beta-blockers 35% and rifaximin 31%. 90% were admitted for liver-related reasons;GI bleed 30%, HE 34%, AKI 33%, electrolyte issues 30%, anasarca 24% and 25% admission infections. In-hospital course: Median LOS was 7 (1–140) days with 25% needing ICU. 15% died in hospital, 3% were transplanted, 46% developed AKI,15% grade 3–4 HE, 14% shock, 13% nosocomial infections and 13% needed ventilation. Logistic Regression: Fig B shows that liver-related/unrelated factors on admission which predicted in-hospital mortality and development of organ dysfunction with MELDNa and Infections being common among all models. Nosocomial infections and organ dysfunctions predicted mortality when all variables were considered. High-income countries had better mortality outcomes likely due to transplant and ICU availability. AUCs were >0.75 (Figure Presented) Conclusion: In this worldwide equitable experience, admission cirrhosis severity and infections are associated with inpatient outcomes, which are greater in low-income settings. Liver-related and unrelated factors and regional variations are important in defining critical care goals and outcome models in inpatients with cirrhosis.