The following is a summary of “Global disparities in mortality and liver transplantation in hospitalised patients with cirrhosis: a prospective cohort study for the CLEARED Consortium,” published in the July 2023 issue of Gastroenterology & Hepatology by Bajaj et al.

Cirrhosis, the outcome of hepatic injury, exhibits a significant mortality rate on a global scale. The impact of country-level income on mortality rates associated with cirrhosis remains uncertain. Researcher’s objective was to evaluate factors that can predict mortality in hospitalized patients with cirrhosis by utilizing a worldwide collaboration that emphasizes variables related to cirrhosis and access to healthcare. In this prospective observational cohort study, the CLEARED Consortium conducted a follow-up on inpatients diagnosed with cirrhosis at 90 tertiary care hospitals in 25 countries spanning six continents. Consecutive adult patients aged 18 years and older, who were admitted for non-elective reasons and did not have COVID-19 or advanced hepatocellular carcinoma, were included in the study. 

The primary endpoints included mortality and the occurrence of liver transplantation during the initial hospitalization or within 30 days after discharge. Surveys were conducted to assess the availability and accessibility of diagnostic and treatment services across various healthcare facilities. The outcomes were compared based on the country income level of the participating sites, as per the 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 incorporating demographic variables, etiology of the disease, and disease severity were employed to assess the odds of each outcome linked to the variables of interest. Patients were recruited from November 5, 2021, to August 31, 2022. Data from a total of 3,884 patients were collected during their hospital stay. The average age of the patients was 55.9 years, with a standard deviation of 13.3. Among the patients, 2,493 (64.2%) were men, and 1,391 (35.8%) were women. Out of the total, 1,413 (36.4%) were from high-income countries (HICs), 1,,757 (45.2%) were from upper-middle-income countries (UMICs), and 714 (18.4%) were from low-income countries (LICs) or lower-middle-income countries (LMICs). Unfortunately, 410 patients were lost to follow-up within 30 days after discharge. The total number of deceased patients during their hospital stay was 110 (7·8%) out of 1,413 individuals in high-income countries (HICs), 182 (10·4%) out of 1,757 individuals in upper-middle-income countries (UMICs), and 158 (22·1%) out of 714 individuals in low-income countries (LICs) and lower-middle-income countries (LMICs) (P<0·0001). Similarly, within 30 days after being discharged, the corresponding figures were 179 (14·4%) out of 1,244 individuals in HICs, 267 (17·2%) out of 1,556 individuals in UMICs, and 204 (30·3%) out of 674 individuals in LICs and LMICs (P<0·0001). In comparison to patients from high-income countries (HICs), patients from upper-middle-income countries (UMICs) had a higher risk of death during hospitalization (adjusted odds ratio [aOR] 2.14 [95% CI 1.61-2.84]). 

Similarly, patients from low-income countries (LICs) or lower-middle-income countries (LMICs) also had an increased risk of death during hospitalization (aOR 2.54 [1.82-3.54]). Additionally, both UMICs and LICs or LMICs had an elevated risk of death within 30 days after discharge (aOR 1.95 [1.44-2.65] in UMICs and 1.84 [1.24-2.72] in LICs or LMICs). The occurrence of liver transplantation was documented in 59 (4·2%) out of 1413 patients from high-income countries (HICs), 28 (1·6%) out of 1757 from upper-middle-income countries (UMICs) (adjusted odds ratio [aOR] 0·41 [95% CI 0·24–0·69] compared to HICs), and 14 (2·0%) out of 714 from low-income countries (LICs) and lower-middle-income countries (LMICs) (0·21 [0·10–0·41] compared to HICs) during the initial hospitalization (P<0·0001). Additionally, liver transplantation occurred in 105 (9·2%) out of 1,137 patients from HICs, 55 (4·0%) out of 1372 from UMICs (0·58 [0·39–0·85] compared to HICs), and 16 (3·1%) out of 509 from LICs or LMICs (0·21 [0·11–0·40] compared to HICs) within 30 days after discharge (P<0·0001). The site survey findings revealed geographical disparities in the availability of crucial pharmaceuticals (such as rifaximin, albumin, and terlipressin) as well as medical procedures (including emergency endoscopy, liver transplantation, intensive care, and palliative care). 

Patients diagnosed with cirrhosis who are admitted to low-income countries (LICs), lower-middle-income countries (LMICs), or upper-middle-income countries (UMICs) experience a notably elevated mortality rate compared to patients admitted to high-income countries (HICs), regardless of their medical risk factors. This disparity in mortality rates could be attributed to inequities in the availability of crucial diagnostic and therapeutic services. These findings should prompt researchers and policymakers to consider the availability of medical services and medications when assessing outcomes related to cirrhosis.

Source: sciencedirect.com/science/article/abs/pii/S2468125323000985