Global disparities in mortality and liver transplantation in hospitalised patients with cirrhosis: a prospective cohort study for the CLEARED Consortium

医学 肝移植 肝硬化 队列 肝病 酒精性肝病 移植 内科学 前瞻性队列研究 重症监护医学
作者
Jasmohan S. Bajaj,Ashok Choudhury,Qing Xie,Patrick S. Kamath,Mark Topazian,Peter C. Hayes,Aldo Torre,Hailemichael Desalegn,Ramazan İdilman,Zhujun Cao,Marcelo Silva,Jacob George,Brian J. Bush,Leroy R. Thacker,Florence Wong,Shiv Kumar Sarin,Shiva Kumar,Sebastián Marciano,Adrián Gadano,Fiona Tudehope,Robert N. Gibson,Alexander Prudence,Adam Doyle,Hooi Ling,Stephen M. Riordan,Alberto Queiróz Farias,Patricia Momoyo Zitelli,Chinmay Bera,Nabiha Faisal,Puneeta Tandon,Monica Dahiya,Marie Jeanne Lohoues,Ponan Claude Regis Lah,Carlos Alberto Velasco Benítez,Marco Arrese,Yongchao Xian,Jin Guan,Chuanwu Zhu,Yingling Wang,Minghua Su,Man Su,Yanhang Gao,Xinrui Wang,Yongfang Jiang,Jing Ma,Caiyan Zhao,Wei Wang,Lei Wang,Dedong Yin,Mingqin Lu,Yi-Jing Cai,Ning‐Ping Zhang,Wanqin Zhang,Hai Li,Fuchen Dong,Xin Zheng,Jing Liu,Hong Tang,Libo Yan,Bin Xu,Linlin Wei,Zhiliang Gao,Zhen Xu,Minghua Lin,Gao Hai-bin,Jinjun Chen,Beiling Li,Chenghai Liu,Yanyun Zhang,Peng Hu,Huan Deng,Hibat Allah Belimi,N. Debzi,Henok Fisseha,Aloysious Aravinthan,Suresh Vasan Venkatachalapathy,Neil Rajoriya,Rosemary Faulkes,Damien Leith,Ewan Forrest,Danielle Adebayo,James Kennedy,Diana E. Yung,Wai‐Kay Seto,James Fung,Helena Katchman,Liane Rabinowich,Aabha Nagral,Ashwin Deshmukh,Anand J. Kulkarni,Mithun Sharma,C. E. Eapen,Ashish Goel,Akash Gandotra,Ajay Duseja,Anoop Saraya,Jatin Yegurla,Mohamed Rela,Dinesh Jothimani,Ashish Kumar,Ashish Kumar,Radha K. Dhiman,Akash Roy,Anil C. Anand,Dibyalochan Praharaj,Sarai Gonzalez Hueso,Araceli Bravo Cabrera,José Luis Pérez Hernández,Orlando M. Gutiérrez,Godolfino Miranda Zazueta,Abraham Ramos-Pineda,Mauricio Castillo Barradas,René Malé Velazquez,Lilian Torres Made,J.A. Velarde-Ruiz Velasco,Francisco A. Félix-Téllez,Jacqueline Córdova‐Gallardo,Ruveena Bhavani Rajaram,Nik Arsyad Nik Muhamad Affendi,Edith Okeke,David Nyam,Dalia Allam,Yashwi Haresh Kumar Patwa,Han Khim Tan,Wei Lun Liou,Sombat Treeprasertsuk,Salisa Wejnaruemarn,Busra Haktaniyan,Feyza Gündüz,Rahmi Aslan,Abdullah Emre Yıldırım,Sezgin Barutçu,Zeki Karasu,Alper Uysal,Enver Üçbilek,Tolga Kosay,Haydar Adanır,Dinç Dinçer,Somaya Albhaisi,Sumeet K. Asrani,Mohammad Amin Fallahadeh,K. Rajender Reddy,Suditi Rahematpura,Jawaid Shaw,Hugo E. Vargas,David Bayne,Scott W. Biggins,Natalia Filipek,Paul J. Thuluvath,Somya Sheshadri,Andrew P. Keaveny,Andres Duarte Rojo,Ricardo Cabello Negrillo
出处
期刊:The Lancet Gastroenterology & Hepatology [Elsevier]
卷期号:8 (7): 611-622 被引量:8
标识
DOI:10.1016/s2468-1253(23)00098-5
摘要

Background Cirrhosis, the end result of liver injury, has high mortality globally. The effect of country-level income on mortality from cirrhosis is unclear. We aimed to assess predictors of death in inpatients with cirrhosis using a global consortium focusing on cirrhosis-related and access-related variables. Methods In this prospective observational cohort study, the CLEARED Consortium followed up inpatients with cirrhosis at 90 tertiary care hospitals in 25 countries across six continents. Consecutive patients older than 18 years who were admitted non-electively, without COVID-19 or advanced hepatocellular carcinoma, were enrolled. We ensured equitable participation by limiting enrolment to a maximum of 50 patients per site. Data were collected from patients and their medical records, and included demographic characteristics; country; disease severity (MELD-Na score); cirrhosis cause; medications used; reasons for admission; transplantation listing; cirrhosis-related history in the past 6 months; and clinical course and management while hospitalised and for 30 days post discharge. Primary outcomes were death and receipt of liver transplant during index hospitalisation or within 30 days post discharge. Sites were surveyed regarding availability of and access to diagnostic and treatment services. Outcomes were compared by country income level of participating sites, defined according to World Bank income classifications (high-income countries [HICs], upper-middle-income countries [UMICs], and low-income or lower-middle-income countries [LICs or LMICs]). Multivariable models controlling for demographic variables, disease cause, and disease severity were used to analyse the odds of each outcome associated with variables of interest. Findings Patients were recruited between Nov 5, 2021, and Aug 31, 2022. Complete inpatient data were obtained for 3884 patients (mean age 55·9 years [SD 13·3]; 2493 (64·2%) men and 1391 (35·8%) women; 1413 [36·4%] from HICs, 1757 [45·2%] from UMICs, and 714 [18·4%] from LICs or LMICs), with 410 lost to follow-up within 30 days after hospital discharge. The number of patients who died while hospitalised was 110 (7·8%) of 1413 in HICs, 182 (10·4%) of 1757 in UMICs, and 158 (22·1%) of 714 in LICs and LMICs (p<0·0001), and within 30 days post discharge these values were 179 (14·4%) of 1244 in HICs, 267 (17·2%) of 1556 in UMICs, and 204 (30·3%) of 674 in LICs and LMICs (p<0·0001). Compared with patients from HICs, increased risk of death during hospitalisation was found for patients from UMICs (adjusted odds ratio [aOR] 2·14 [95% CI 1·61–2·84]) and from LICs or LMICs (2·54 [1·82–3·54]), in addition to increased risk of death within 30 days post discharge (1·95 [1·44–2·65] in UMICs and 1·84 [1·24–2·72] in LICs or LMICs). Receipt of a liver transplant was recorded in 59 (4·2%) of 1413 patients from HICs, 28 (1·6%) of 1757 from UMICs (aOR 0·41 [95% CI 0·24–0·69] vs HICs), and 14 (2·0%) of 714 from LICs and LMICs (0·21 [0·10–0·41] vs HICs) during index hospitalisation (p<0·0001), and in 105 (9·2%) of 1137 patients from HICs, 55 (4·0%) of 1372 from UMICs (0·58 [0·39–0·85] vs HICs), and 16 (3·1%) of 509 from LICs or LMICs (0·21 [0·11–0·40] vs HICs) by 30 days post discharge (p<0·0001). Site survey results showed that access to important medications (rifaximin, albumin, and terlipressin) and interventions (emergency endoscopy, liver transplantation, intensive care, and palliative care) varied geographically. Interpretation Inpatients with cirrhosis in LICs, LMICs, or UMICs have significantly higher mortality than inpatients in HICs independent of medical risk factors, and this might be due to disparities in access to essential diagnostic and treatment services. These results should encourage researchers and policy makers to consider access to services and medications when evaluating cirrhosis-related outcomes. Funding National Institutes of Health and US Department of Veterans Affairs.
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