Disparities in transplant access drive mortality in low, middle-income countries
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WASHINGTON — Patients with cirrhosis in low- or middle-income countries had an increased risk for inpatient and 30-day mortality, likely due to disparities in transplant access, according to research presented at The Liver Meeting.
“Chronic liver disease and cirrhosis are major causes of morbidity and mortality worldwide. We know the differences in etiologies of the disease, population characteristics, and more importantly, the availability of resources differ among sites,” Jasmohan S. Bajaj, MD, FAASLD, professor of gastroenterology, hepatology and nutrition at Virginia Commonwealth University, said. “Models that predict negative outcomes such as death and organ failure need to have a global contribution. In addition, equity and reduction of disparities require us to be aware of resources and population differences between sites.
“Therefore, a global consortium focusing on inpatients with cirrhosis is needed to investigate systematic disparities in inpatient services care,” he said.
Aiming to define the impact of location on the prediction of outcomes, Bajaj and colleagues created the Chronic Liver disease Evolution and Registry for Event and Decompensation (CLEARED) global consortium study and prospectively enrolled 2,758 patients with cirrhosis from 21 countries. Researchers collected admission details, cirrhosis history and inpatient and 30-day outcomes and used the world bank classification of low/low middle income ([LMI] = 727), upper middle income ([UMI] = 1,050) and high income ([HI] = 981) to stratify patients. They used multivariable regression to compare outcomes between groups.
Bajaj noted more patients in the HI group had 6-month hospitalizations and infections, as well as hepatic encephalopathy and ascites; this group also had the highest proportion of patients with alcoholic and nonalcoholic steatohepatitis. Prior variceal bleeding was higher in the LMI group, and prior hepatocellular carcinoma and transplant listings were lower in the LMI group but similar in the UMI and HI groups.
Admission trends
According to global consortium analysis, patients in the LMI group had the highest MELD score at admission as well as the highest spontaneous bacterial peritonitis prophylaxis and rifaximin; this group also had higher spontaneous bacterial peritonitis (36% vs. 24% vs. 21%, respectively) and lowest skin or soft tissue infections (5% vs. 5% vs. 10%).
The highest proportion of nosocomial infections were reported in the LMI and HI groups (15% vs. 14% vs. 11%) and were mostly UTI. Patients in the HI group had lower antiviral use and higher admission diuretics, proton pump inhibitors, lactulose and statins.
Outcome data
A higher proportion of patients in the LMI group required ICU support and experienced organ failure. Discharge MELD and in-hospital mortality was highest in this group, while transplant was lowest.
In-hospital mortality correlated with age, infection, MELD and residence in an LMI or UMI country compared with a HI country, while being on the transplant list, diabetes and spontaneous bacterial peritonitis prophylaxis were protective. Age, ascites, HCC, discharge MELD, organ failures and LMI/UMI vs. HI predicted 30-day mortality while rifaximin was protective.
In-hospital transplant was higher among patients with a higher MELD score, admission rifaximin and those listed for transplant while it was lower among patients in the LMI group (OR = 0.26) and UMI group (OR = 0.22). Further, 30-day transplant was higher among patients with hyponatremia and ascites as well as those listed for transplant. It was lower among patients in the LMI (OR = 0.24) and UMI (OR = 0.59) groups compared with patients in the HI group.
“In this global consortium of inpatients with cirrhosis which had an equitable distribution of patients per site, there were major differences in outcomes,” Bajaj concluded. “Not being in high-income countries significantly increased the risk for 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.”
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Bajaj JS, et al. Abstract 142. Differences in mortality rates in inpatients with cirrhosis depends on the low-, middle- or high-income country location: Multinational CLEARED consortium experience. Presented at: The Liver Meeting; Nov. 4-8, 2022; Washington (hybrid meeting).
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