Predictors of In-hospital Mortality among Cirrhotic Patients in Ethiopia: A Multicenter Retrospective Study

Predictors of In-hospital Mortality among Cirrhotic Patients in Ethiopia: A Multicenter Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictors of In-hospital Mortality among Cirrhotic Patients in Ethiopia: A Multicenter Retrospective Study Tamrat Petros Elias, Abate Bane Shewaye, Henok Fisseha, Abdulsemed Mohammed Nur, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4828463/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Cirrhosis is a major global health problem and a leading cause of liver-related mortality. In Ethiopia specifically, cirrhosis is the 6th leading cause of death and is responsible for high hospitalization and mortality rates. However, until now, factors affecting in-hospital mortality in patients admitted due to complications of liver cirrhosis are poorly understood. This study assessed the predictors of in-hospital mortality among cirrhotic patients in Ethiopia. Methods A retrospective cross-sectional study using data collected from the electronic medical records of patients who were admitted for complications of liver cirrhosis between January 1, 2023, and March 31, 2024, in the medical wards of Adera Medical Center, St. Paul’s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Frequency and cross-tabulation were used for descriptive statistics. Predictor variables with a p-value < 0.25 in bivariate analyses were included in the logistic regression. The adjusted odds ratio (AOR) with the corresponding 95% confidence interval (CI) was calculated to show the strength of the association. A p-value < 0.05 was considered statistically significant. Results Of the 299 patients included in the final analysis, the majority (79.6%) were males, and the median age of the study participants was 45 (IQR, 36–56) years. Hepatitis B virus (32.1%) was the most common etiology, followed by alcohol (30.1%) and hepatitis C virus (13.4%). More than half (52.9%) of the patients were in Child-Pugh class C, and around a quarter (26.1%) of the patients had comorbidities. Ascites (69.2%), Upper gastrointestinal bleeding (50.5%), and hepatic encephalopathy (44.8%) were the most common forms of presentation. The in-hospital mortality rate was 25.4%. West Haven Grade III or IV hepatic encephalopathy (AOR: 12.0; 95% CI 2.33–61.63; P < 0.01), Hepatocellular Carcinoma (AOR: 9.05; 95% CI 2.18–37.14; P: 0.01), History of previous admission within one year period (AOR: 6.80; 95% CI 2.18–21.18; P < 0.01), Acute Kidney Injury (AOR: 6.47; 95% CI 1.77–23.64; P < 0.01), and Model for End-Stage Liver Disease – Sodium (MELD-Na) Score (AOR: 1.17; 95% CI 1.05–1.30; P: 0.02), were found to be predictors of in-hospital mortality. Conclusion In-hospital mortality of cirrhotic patients is high in Ethiopia. West Haven grade III or IV hepatic encephalopathy is the leading cause of mortality. Hence, Prompt identification and management of hepatic encephalopathy and its precipitant at an earlier stage is crucial for better treatment outcomes and survival. Cirrhosis In-hospital mortality Ethiopia Introduction Cirrhosis is the fibrotic replacement of liver tissue that can result from any chronic liver disease (CLD) [ 1 ]. It is a leading cause of liver-related death worldwide. Globally, the estimated number of deaths associated with cirrhosis in 2019 was 1.47 million accounting for 2.4% of all-cause mortality. This number increased by 10% after 2010 [ 2 ]. According to the global burden of disease super-regions for 2017, the age-standardized death rate was highest in sub-Saharan Africa [ 3 ]. In Ethiopia, cirrhosis is the 6th leading cause of mortality, accounting for 24 deaths/100,000 population [ 4 ]. In the initial stages, cirrhosis is compensated and patients are asymptomatic. Decompensation is usually defined as the first occurrence of ascites, esophageal variceal bleeding, or hepatic encephalopathy [ 3 ]. The transition from a compensated state to a decompensated state occurs at a rate of 5–12% per year [ 2 ]. Once decompensation occurs, the mortality and morbidity resulting from cirrhosis also increase sharply, and the 1-year case-fatality rate can reach 80%. Quality of life is also affected and frequent hospitalizations (admissions and stays) are needed [ 3 ]. When patients with cirrhosis of the liver are hospitalized, mortality increases significantly, ranging from 44 to 74% [ 5 ]. The major etiologies of cirrhosis are hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, alcohol-associated liver disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). Globally, among individuals with cirrhosis, 42% had HBV infection and 21% had HCV infection [ 2 ]. In sub-Saharan Africa, 69% of liver cirrhosis cases are attributed to HBV, HCV, and alcohol consumption [ 6 ]. Hepatitis B virus (40%), alcohol (17%), and hepatitis C virus (15%) are the three most common etiologies of CLD in Ethiopia [ 7 ]. In Ethiopia, liver disease accounts for 12% of admissions and 31% of hospital mortality in adult medical wards [ 8 ]. On the other hand, the overall hospital mortality rate in CLD patients ranges from 25–41% [ 7 , 9 ]. However, the factors affecting in-hospital mortality in admitted liver cirrhosis patients are poorly understood in many regions of Africa including Ethiopia [ 3 ]. The few studies conducted in Africa were limited by small sample sizes [ 10 – 13 ]. This study aimed to assess predictors of in-hospital mortality among cirrhotic patients in a larger sample. Methodology Study design A retrospective cross-sectional study design was used to assess the predictors of in-hospital mortality among patients who were admitted with a diagnosis of liver cirrhosis between January 1, 2023, and March 31, 2024, in the medical wards of Adera Medical Center, St. Paul’s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Study area The study was conducted at Adera Medical Center, St. Paul’s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Adera Medical Center is a renowned private health facility in Addis Ababa that provides dedicated gastroenterology and hepatology services for patients from all over the country. St. Paul’s Hospital Millennium Medical College is a tertiary-level teaching hospital under the Federal Ministry of Health with more than 700 beds in inpatient capacity. Tikur Anbessa Specialized Hospital is the largest referral university hospital in the country with more than 800 beds. Study participants All patients ≥ 18 years of age admitted to the medical wards of Adera Medical Center, St. Paul’s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital with the diagnosis of liver cirrhosis between January 1, 2023, and March 31, 2024, were included in the study. Exclusion criteria were admission for non-cirrhosis-related causes, multiple missing variables on the patient charts, admission for observation after prophylactic endoscopic variceal ligation or percutaneous liver biopsy, and unknown outcome of treatment due to referral to other centers or discontinuation of treatment against medical advice. Data collection tools and procedures Sociodemographic (age and sex), clinical (etiology, duration since diagnosis, comorbidity, major signs and symptoms at clinical presentation, history of previous admission within one year, admission diagnosis, prognostic scores at admission, duration of hospital stay, and outcome of hospital admission), laboratory (complete blood count, liver and renal function tests, and electrolytes), and imaging (fibroscan, abdominal ultrasound, computed tomography (CT) scan, and upper gastrointestinal endoscopy) data were extracted from the electronic medical records system between May 1, 2024, and May 31, 2024, by general practitioners working in the health facilities by using a pretested data abstraction format that was prepared by reviewing relevant works of literature. The data quality was ensured through training of the data collectors, close supervision, and prompt feedback. The data were checked for inconsistencies, completeness, accuracy, clarity, coding errors, and missing values, and appropriate corrections were made by the principal investigator. Sample size and statistical analysis The sample size was calculated using Cochran’s formula, assuming a mortality rate of 28.4% according to a previous study [ 10 ], a 95% confidence interval (CI), and a 5% margin of error (d). After adding 10% for the probability of having incomplete data, the sample size was found to be 345. A convenient sampling method was used until the desired sample size was achieved. Statistical Package for Social Sciences (SPSS) version 26 was used to enter and analyze the data. Frequency and cross-tabulation are used to summarize the descriptive statistics of the data. Associations between predictor variables and outcomes of interest are estimated using both bivariate analysis and binary logistic regression. The chi-square test and t-test were used in the bivariate analysis. Predictor variables with a p-value < 0.25 in bivariate analyses are reported and included in the logistic regression. For the binary logistic regression, a 95% confidence interval for adjusted odds ratio (AOR) was calculated and variables with p-value < 0.05 were considered statistically significant. Operational definition Liver cirrhosis was diagnosed based on the presence of two or more of the following 1. Clinical signs of cirrhosis (jaundice, ascites, caput medusa, clubbing, palmar erythema, spider naevi, gynecomastia, female pubic hair pattern, encephalopathy, splenomegaly, or asterixis) 2. Impaired liver function test consistent with cirrhosis (International Normalized Ratio (INR) ≥ 1.5 and serum albumin ≤ 3.4gm/dl) 3. Imaging diagnosis of cirrhosis ( surface nodularity, coarse and heterogeneous echotexture/ attenuation, segmental atrophy or hypertrophy, ascites, splenomegaly, gall bladder wall thickening, or portal vein diameter > 13 mm on abdominal ultrasound and/or CT scan) 4. Transient elastography (FibroScan ® ) > 12.5 Kilopaskal (KPa) 5. AST (aspartate aminotransferase) to Platelet Ratio Index (APRI) score of ≥ 1.5 or Fibrosis-4 (FIB-4) score ≥ 3.25 [ 1 ]. Ethical consideration The study was conducted after obtaining ethical clearance from Adera Medical Center Institutional Review Board (IRB). The IRB of the center waived the need for obtaining informed consent as only anonymized data from participants was collected retrospectively from the electronic medical record system. Confidentiality of individual patient information was maintained by using code numbers instead of other identifiers and the information gained from the chart was used only for research purposes. Results A total of 356 patients were admitted to the medical wards of the three hospitals with a diagnosis of liver cirrhosis: 236 patients at Adera Medical Center, 71 patients at St. Paul's Hospital Millennium Medical College, and 49 patients at Tikur Anbessa Specialized Hospital. Of the 356 patients, 331 patients fulfilled the inclusion criteria, and 32 patients met the exclusion criteria. Hence, 299 patients were included in the final analysis. Sociodemographic and clinical characteristics The median age of the study participants was 45 (interquartile range (IQR), 36–56) years and the majority (79.6%) of patients were males. Hepatitis B virus (32.1%) was the most common etiology followed by alcohol (30.1%) and hepatitis C virus (13.4%). The cause of cirrhosis was not identified in 12% of the patients. Metabolic dysfunction-associated steatotic liver disease (MASLD), autoimmune hepatitis, and Budd Chiari syndrome accounted for 7.4%, 6.4%, and 2.3% of the etiology respectively. More than half (52.9%) of the patients were in the Child-Pugh class C category, 35.2% were in class B, and 11.9% were in class A. Approximately one-quarter (26.1%) of the patients had comorbidities. Diabetes (17.1%) was the most common comorbidity followed by hypertension (9.7%). From the signs and symptoms at admission, ascites (69.2%) and fatigue (56.2%) were the most common. Half (50.5%) of the patients presented with upper GI bleeding (UGIB). All patients who presented with UGIB were found to have bleeding esophageal varices on endoscopic evaluation. Hepatic encephalopathy was present in 44.8% of the patients. The encephalopathy was grade one (13.4%), two (55.2%), three (23.9%), and four (7.5%) based on the West Haven criteria. UGIB (27.6%) was the most common precipitant for encephalopathy followed by electrolyte imbalance (23.1%) and spontaneous bacterial peritonitis (SBP) (14.2%). One-fourth (25.8%) of the patients had acute kidney injury (AKI) and 24.8% of the patients had SBP. Hepatocellular carcinoma (HCC) was present in 18.4% of the study participants. Factors associated with in-hospital mortality Of the 299 patients included in the study, 76 patients (25.4%) have passed away in the hospital. As shown in Table 1 , factors associated with in-hospital mortality in the bivariate analysis were, age, jaundice, ascites, pedal edema, change in mentation, sleep disturbance, admission within one year, AKI, HCC, hepatic encephalopathy, MELD-Na score, and child-pugh score. From the laboratory parameters, leukocyte count, hemoglobin, AST (aspartate aminotransferase), ALT (alanine aminotransferase), ALP (alkaline phosphatase), bilirubin level, serum albumin, INR (international normalized ratio), creatinine, urea, and serum sodium level have a statistically significant correlation with in-hospital mortality (Table 1 ). Table 1 Bivariate analysis of factors associated with in-hospital mortality Characteristics Discharged alive Death P-Value Median Age in Years (IQR) 45.0 (35.0–55.0) 48.5 (39.25–57.25) 0.02 Gender 0.62 Male 176 (73.9%) 62 (26.1%) Female 47 (77.0%) 14 (23.0%) Etiology of cirrhosis Alcohol 66 (73.3%) 24 (26.7%) 0.74 Hepatitis B Virus 72 (75.0%) 24 (25.0%) 0.90 Hepatitis C Virus 27 (67.5%) 13 (32.5%) 0.27 MASLD 20 (90.9%) 2 (9.1%) 0.06 Autoimmune hepatitis 15 (78.9%) 4 (21.1%) 0.65 Budd-Chiari Syndrome 5 (71.4%) 2 (28.6%) 0.84 Unknown 25 (69.4%) 11 (30.6%) 0.45 Comorbidity 0.14 Yes 63 (80.7%) 15 (19.3%) No 160 (72.4%) 61 (27.6%) Specific comorbidity Diabetes 44 (86.3%) 7 (13.7%) 0.08 Hypertension 23 (79.3%) 6 (20.7%) 0.53 Asthma or COPD 10 (90.9%) 1 (9.1%) 0.20 HIV 2 (50.0%) 2 (50.0%) 0.25 Chronic kidney disease 8 (72.7%) 3 (27.3%) 0.88 Sign and Symptom Fatigue 115 (68.5%) 53 (31.5%) 0.16 Jaundice 86 (60.6%) 56 (39.4%) < 0.01 Ascites 146 (70.5%) 61 (29.5%) 0.01 Pedal edema 66 (61.1%) 42 (38.9%) < 0.01 Change in mentation 49 (51.6%) 46 (48.4%) < 0.01 Sleep disturbance 50 (61.7%) 31 (38.3%) 0.04 Melena or hematemesis 123 (84.8%) 22 (15.2%) 0.53 History of admission within one year < 0.01 Yes 60 (60.6%) 39 (39.4%) No 163 (81.5%) 37 (18.5%) Diagnosis at admission SBP 52 (70.3%) 22 (29.7%) 0.32 AKI 33 (42.8%) 44 (57.2%) < 0.01 Variceal UGIB 127 (84.1%) 24 (15.9%) 0.78 Hepatic encephalopathy <0.01 Grade I or II 66 (71.7%) 26 (28.3%) Grade III or IV 11 (26.2%) 31 (73.8%) HCC 33 (60.0%) 22 (40.0%) < 0.01 Laboratory Parameters (Mean ± SD) Leukocyte count 7.5 ± 4.3 11.0 ± 5.4 < 0.01 Hemoglobin 11.5 ± 3.0 10.7 ± 2.7 0.03 AST 129.9 ± 58.5 279.7 ± 68.9 < 0.01 ALT 84.0 ± 61.7 176.6 ± 77.1 < 0.01 ALP 231.9 ± 71.6 392.9 ± 86.5 < 0.01 Total Bilirubin 4.1 ± 1.8 10.5 ± 2.7 < 0.01 Serum albumin 2.8 ± 0.7 2.5 ± 0.6 0.01 INR 1.6 ± 0.4 2.0 ± 0.9 < 0.01 Creatinine 1.1 ± 0.6 2.0 ± 1.4 < 0.01 Serum Sodium 133.1 ± 8.3 128.0 ± 10.3 0.01 Serum Potassium 3.9 ± 0.7 4.4 ± 0.9 0.47 Mean duration of stay in days 6.4 ± 4.2 7.6 ± 3.7 0.21 Mean Child-Pugh Score 9.0 ± 2.2 11.9 ± 1.9 < 0.01 Mean MELD-Na Score 18.8 ± 7.3 30.1 ± 6.2 < 0.01 Multivariate analysis was performed by using binary logistic regression to identify associations between variables with a P-value less than 0.05 in the bivariate analysis and in-hospital mortality. A history of previous admission within one year period (AOR: 6.80; 95% CI 2.18–21.18; P < 0.01), Grade III or IV hepatic encephalopathy (AOR: 12.0; 95% CI 2.33–61.63; P < 0.01), AKI (AOR: 6.47; 95% CI 1.77–23.64; P < 0.01), HCC (AOR: 9.05; 95% CI 2.18–37.14; P: 0.01), and MELD-Na Score (AOR: 1.17; 95% CI 1.05–1.30; P: 0.02), were found to have a statistically significant association with in-hospital mortality (Table 2 ). Table 2 Crude and adjusted odds ratio of predictors of In-hospital mortality Characteristics COR (95% CI) P-Value AOR (95% CI) P-Value Grade III or IV HE 4.2 (3.0–5.8) < 0.01 12.0 (2.3–61.6) < 0.01 HCC 1.8 (1.2–2.7) < 0.01 9.0 (2.2–37.1) 0.01 Admission within one year 2.1 (1.4–3.1) < 0.01 6.8 (2.2–21.2) < 0.01 AKI 3.9 (2.7–5.7) < 0.01 6.5 (1.7–23.6) < 0.01 MELD-Na Score - - 1.2 (1.1–1.3) < 0.01 Discussion In Ethiopia, cirrhosis of the liver is the cause of close to one-third of deaths in adult medical wards [ 8 ]. However, the predictors of in-hospital mortality among cirrhotic patients have not been well-studied. This study aimed to assess these factors in two referral teaching hospitals and one medical center with specialized gastroenterology and hepatology services. A total of 356 cirrhotic patients were admitted to the three health facilities during the study period, of which, 299 patients fulfilled the inclusion criteria and were included in the final analysis. The majority (79.6%) of patients were males. The median age of the study participants was 45 (IQR, 36–56) years and Hepatitis B virus (32.1%) was the most common etiology. More than half (52.9%) of the patients were in the Child-Pugh class C category. The prevalence of in-hospital mortality was 25.4%. In the binary logistic regression, history of previous admission within one one-year period, Grade III or IV hepatic encephalopathy, AKI, HCC, and MELD-Na Score were found to be significantly associated with in-hospital mortality. The median age of the patients admitted to the hospitals was 45 (IQR, 36–56) years. This relatively young age is concerning, as cirrhosis can significantly impact patients' quality of life and life expectancy. This can have major socioeconomic consequences and can lead to disability, lost productivity, and the need for significant medical care and support. A similar age group was reported in Ethiopia [ 9 ] and other African studies [ 11 – 13 ]. However, this age is lower than those found in previous US [ 14 ] and European [ 15 ] research. This could be because of the high viral hepatitis burden and a limited access to quality healthcare and liver disease screening in many African settings which can lead to delayed diagnoses, allowing earlier stages of hepatitis to progress further before patients receive appropriate management. The majority (79.6%) of the patients in this study were males. A higher prevalence of cirrhosis in males was reported in multiple other studies [ 16 – 18 ]. The higher prevalence of liver cirrhosis and its complications in men is likely due to a combination of behavioral factors such as alcohol consumption, and biological factors such as lower levels of estrogen, which have been shown to have anti-fibrotic and anti-inflammatory effects on the liver that collectively increase their susceptibility to the development and progression of various liver diseases leading to cirrhosis [ 19 ]. In our study, the most common etiology was hepatitis B virus (32.1%) followed by alcohol (30.1%) and hepatitis C virus (13.4%). HBV was also reported as the leading cause of cirrhosis in other studies conducted in Ethiopia [ 7 , 9 ]. Similar results were observed in research done in Togo [ 20 ], Ghana [ 21 ], Nigeria [ 22 ], and other Sub-Saharan African countries [ 23 ]. HCV is the major cause of cirrhosis in the Eastern Mediterranean region[ 2 , 24 ] and North Africa [ 25 , 26 ]. Alcohol was the dominant etiology in reports from India [ 18 , 27 ], Thailand [ 28 ], and Colombia[ 16 ]. Although lower than the global average, the peculiar finding in our study, when compared to other similar studies in Ethiopia, is the increasing prevalence of alcohol related liver disease and MASLD. This can be linked to the increasing trends in hazardous alcohol consumption[ 29 ] and metabolic risk factors for MASLD such as diabetes[ 30 ] in Ethiopia. This was also evident in our study, which revealed that 17.1% of the patients had diabetes and 26.1% of the patients had comorbidities. This represents a substantial change from an earlier Ethiopian study that reported the prevalence of diabetes and comorbidities in general to be 6.4% and 11% respectively [ 10 ]. This finding aligns with the global pattern that indicates the impending eclipse of the influence of viral hepatitis by emergent metabolic CLDs [ 2 ]. Ascites (69.2%), UGIB (50.5%), and hepatic encephalopathy (44.8%) were the most common presentations in this study. This finding significantly differs from those of former studies conducted in Ethiopia which reported UGIB to be present in 10.2% and 25.7% of the cases [ 9 , 10 ]. The figure in our study is also higher than those reported by researchers from the United States (8.6%), Madagascar (33.3%), and Colombia (17.3%) [ 11 , 14 , 16 ]. The primary reason for this is that patients are usually referred to these centers for therapeutic endoscopic interventions due to the restricted availability of these services at other hospitals. The most frequent precipitant of hepatic encephalopathy in our patients was likewise discovered to be UGIB, which may account for why our study's prevalence of hepatic encephalopathy was higher than that of previous investigations. In this study, the in-hospital mortality rate was 25.4%. This is comparable with the 25.9% and 23.5% in-hospital mortality rates that have been reported from studies previously conducted in Madagascar and Colombia, respectively [ 11 , 16 ]. However, this percentage was less than that reported by studies carried out in Saudi Arabia (35%), Ghana (41.9%), and the Ivory Coast (42.2%) and much greater than that reported in Pakistan (15.7%), Morocco (8.7%), and the US (6.6%). These discrepancies may have resulted from variances in the study settings, as the study in Saudi Arabia included patients admitted to the ICU, and the baseline characteristics of the patients. These attributes include the stage of the disease, related comorbidities, specific complications of liver cirrhosis that resulted in hospitalization, and the clinical condition of the patients at admission. The higher mortality rate seen in the current study compared to that of the US, Pakistan, and Morocco can also be attributed to patients' delayed presentations and the lack of treatment options, such as shunt surgeries, which serve as a bridge to more definitive options such as liver transplantation nationwide. Hepatic encephalopathy is one of the most common complications of liver cirrhosis and results in a spectrum of neuropsychiatric symptoms caused by circulating gut-derived toxins of nitrogenous compounds. West Haven Grade III or IV hepatic encephalopathy was found to be an independent predictor of in-hospital mortality. Multiple similar findings were reported from Ghana, Morocco, Madagascar, and the United States [ 11 , 25 , 31 , 32 ]. This underlines the need for prompt identification of hepatic encephalopathy and its precipitant at an earlier stage, followed by proper management. History of previous admission within one year was 33.1% and was also found to be a predictor of in-hospital mortality in the logistic regression. A similar finding was reported in Spain and Canada [ 33 , 34 ]. One possible explanation for the greater death rate in our patients with a history of readmission could be the substantially greater prevalence of hepatic encephalopathy (59.6% vs. 37.5%) in this group of patients than in the patients without such a history. Hepatic encephalopathy was also found to increase readmission and mortality in a study conducted in Italy [ 35 ]. This may also be exacerbated by the unavailability of rifaximin in Ethiopia, which has been demonstrated to lower the risk of overt hepatic encephalopathy recurrence [ 36 ]. Patients with cirrhosis may have acute kidney damage (AKI) for a variety of reasons. Some of these include hepatorenal syndrome (HRS), which is characterized by renal vasoconstriction secondary to splanchnic pooling of blood that reduces the effective circulating blood volume; decreased renal perfusion due to gastrointestinal bleeding; use of diuretics; diarrhea caused by the use of lactulose or infections; and so on [ 37 ]. Regardless of the etiology, AKI was associated with increased in-hospital mortality in our study, which is similar to the findings of studies in the United States and Turkey [ 38 , 39 ]. This was also demonstrated in another systematic review and meta-analysis [ 40 ]. The MELD Na score was also found to be an independent predictor of in-hospital mortality in our study. Similar studies performed in Brazil, and Poland also showed that the MELD Na score predicts in-hospital mortality in cirrhotic patients [ 41 , 42 ]. HCC was the other predictor of hospital mortality in this study. Similar findings were reported in other Sub-Saharan African countries such as Ivory Coast and Ghana [ 13 , 43 ]. However, the presence of HCC was not found to be a predictor of in-hospital mortality in research done in the US [ 14 ]. Because of poor screening and surveillance of HCC in cirrhotic patients, 95% of HCC cases in Sub-Saharan Africa are diagnosed late in the advanced or terminal stages, whereas 40% of cases in high-income countries are diagnosed at an early stage [ 44 ]. This, combined with the very limited availability of curative therapies, may have contributed to the results observed in our study. UGIB was not shown to predict in-hospital mortality. The literature shows mixed results on the effect of UGIB on in-hospital mortality. A previous study done in Ethiopia [ 10 ] and another study conducted in Ghana [ 12 ] showed a significant association. In contrast, a study from France [ 45 ] showed a different result. Endoscopic therapy and antibiotic prophylaxis were shown to be independent predictors of survival in the French study. The reduced mortality found in our study could be due to the relatively better availability of interventional endoscopic services in the centers where our research was conducted, coupled with the current standard use of short-term antibiotic prophylaxis for SBP. The major limitation of our study emanates from its retrospective design. The information collected from the electronic medical records included medical history, physical examination, and laboratory and imaging investigations ordered and documented by the treating physicians. This led us to remove some important parameters, such as nutritional status assessment with body mass index, from our study because these parameters were not available in almost all of the patient files. A significant number of patients were also excluded from the study because of multiple missing variables in their workups. Conclusion In conclusion, in-hospital mortality in cirrhotic patients is high in Ethiopia. West Haven grade III or IV hepatic encephalopathy, History of previous admission within one year period, AKI, HCC, and MELD-Na Score, were found to be predictors of in-hospital mortality. Prompt identification and management of hepatic encephalopathy and its precipitant at an earlier stage is crucial. Routine screening for HCC in patients with cirrhosis is also important for diagnosing and treating the disease at an earlier stage. Patients with a history of admission within a year, AKI, and high MELD Na score also need closer follow-up for a better treatment outcome and survival. Abbreviations MELD-Na: Model for End-Stage Liver Disease – Sodium CLD: Chronic liver disease HBV: Hepatitis B Virus HCV: Hepatitis C Virus MASLD: Metabolic dysfunction associated steatotic liver disease CT: Computed tomography AST: Aspartate aminotransferase ALT: Alanine aminotransferase ALP: Alkaline phosphatase APRI: Aspartate aminotransferase to platelet ratio index KPa: Kilopascal FIB-4: Fibrosis-4 UGIB: Upper gastrointestinal bleeding SBP: Spontaneous bacterial peritonitis AKI: Acute kidney injury HCC: Hepatocellular carcinoma INR: International normalized ratio Declarations Ethics approval and consent to participate Ethics approval was obtained from the institutional review board of Adera medical and surgical center, Ref No: 087/24. The IRB of the center waived the need for obtaining informed consent as only anonymized data from participants was collected retrospectively from the electronic medical record system. Confidentiality of individual patient information was maintained by using code numbers instead of other identifiers and the information gained from the chart was used only for research purposes. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this manuscript. Competing interests The authors declare that they have no competing interests. Funding The study received no funding. Authors' contribution TE, AS, and AN initiated the concept of the study. TE, AS, AM, and KB are involved in the study design. TE, KB, AM, KK, and BS are involved in data acquisition. TE, KB, and HF are involved in data interpretation. TE, AS, HF, and AN are involved in manuscript writing. All authors have read and approved the manuscript. 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Sociodemographic characteristics, complications requiring hospital admission and causes of in-hospital death in patients with liver cirrhosis admitted at a district hospital in Ghana. PLoS One. 2021 Jun 1;16(6 June). Okon JB, Diakite M, Ake F, Kouadio OK, Kone A. Mortality Factors for Cirrhotics in an Ivorian University Hospital (Ivory Coast). Open J Gastroenterol. 2020;10(09):231–41. Mellinger JL, Richardson CR, Mathur AK, Volk ML. Variation among United States hospitals in inpatient mortality for cirrhosis. Clinical Gastroenterology and Hepatology. 2015 Mar 1;13(3):577–84. Riggio O, Celsa C, Calvaruso V, Merli M, Caraceni P, Montagnese S, et al. Hepatic encephalopathy increases the risk for mortality and hospital readmission in decompensated cirrhotic patients: a prospective multicenter study. Front Med (Lausanne). 2023;10. Zubieta-Rodríguez R, Gómez-Correa J, Rodríguez-Amaya R, Ariza-Mejia KA, Toloza-Cuta NA. Hospital mortality in cirrhotic patients at a tertiary care center. Revista de Gastroenterología de México (English Edition). 2017 Jul;82(3):203–9. Jun BG, Lee WC, Jang JY, Jeong SW, Kim YD, Cheon GJ, et al. Follow-up creatinine level is an important predictive factor of in-hospital mortality in cirrhotic patients with spontaneous bacterial peritonitis. J Korean Med Sci. 2018 Mar 19;33(12). Bal CK, Daman R, Bhatia V. Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis. World J Hepatol. 2016 Apr 28;8(12):566–72. Rubin JB, Sundaram V, Lai JC. Gender Differences among Patients Hospitalized with Cirrhosis in the United States. J Clin Gastroenterol. 2020 Jan 1;54(1):83–9. Bagny A, Bouglouga O, Lawson-Ananissoh LM, Dusabe A, Kaaga YL, Balaka A, et al. Quality of Life of the Patients Suffering from Chronic Liver Diseases at the University Health Center Campus of Lome. Open J Gastroenterol. 2015;05(07):88–93. Ofori-Asenso R, Agyeman AA. Hepatitis B in Ghana: A systematic review & meta-analysis of prevalence studies (1995-2015). BMC Infect Dis. 2016;16(1). Adekanle O, Ijarotimi O, Obasi E, Anthony-Nwojo N, Ndububa D. A Southwest Nigerian tertiary hospital 5-year study of the pattern of liver disease admission. NIGERIAN JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY. 2020;12(1):18. Spearman CW, Sonderup MW. Health disparities in liver disease in sub-Saharan Africa. Vol. 35, Liver International. Blackwell Publishing Ltd; 2015. p. 2063–71. Samonakis DN, Koulentaki M, Coucoutsi C, Augoustaki A, Baritaki C, Digenakis E, et al. Clinical outcomes of compensated and decompensated cirrhosis: A long term study. World J Hepatol. 2014;6(7):504–12. Charif I, Saada K, Mellouki I, El Yousfi M, Benajah D, El Abkari M, et al. Predictors of Intra-Hospital Mortality in Patients with Cirrhosis. Open J Gastroenterol. 2014;04(03):141–8. Abd-Elrazek MM, El-Gharabawy NM, Atlam SA, Gabr MA. Clinical Characteristics and Etiology of Chronic Liver Disease among Egyptian Patients in Nile Delta: A Clinical Study. Int J Trop Dis Health. 2022 Aug 9;25–35. Kudru CU, Eshwara VK, Nagiri SK, Guddattu V. Spectrum of bacterial infections and predictors of mortality in adult cirrhotic patients. Med Pharm Rep. 2019;92(4):356–61. Bunchorntavakul C, Hospital R, Charoen A. Nutritional status and its impact on clinical outcomes for patients admitted to Hospital with Cirrhosis [Internet]. 2016. Available from: https://www.researchgate.net/publication/302416910 Ayano G, Yohannis K, Abraha M, Duko B. The epidemiology of alcohol consumption in Ethiopia: A systematic review and meta-analysis. Vol. 14, Substance Abuse: Treatment, Prevention, and Policy. BioMed Central Ltd.; 2019. Animaw W, Seyoum Y. Increasing prevalence of diabetes mellitus in a developing country and its related factors. PLoS One. 2017 Nov 1;12(11). Duah A, Agyei-nkansah A, Osei-poku F, Duah F, Ampofo-boobi D, Peprah B. The Prevalence , Predictors , and In-Hospital Mortality of Hepatic Encephalopathy in Patients with Liver Cirrhosis Admitted at St . Dominic Hospital in Akwatia , Ghana. 2020;2020. Bajaj JS, O’Leary JG, Tandon P, Wong F, Garcia-Tsao G, Kamath PS, et al. Hepatic Encephalopathy Is Associated With Mortality in Patients With Cirrhosis Independent of Other Extrahepatic Organ Failures. Clinical Gastroenterology and Hepatology. 2017 Apr 1;15(4):565-574.e4. Bhsc JMM, Dewit Y, Groome P, Djerboua M, Booth CM, Flemming JA. Early hospital readmission and survival in patients with cirrhosis : A population-based study. Morales BP, Planas R, Bartoli R, Morillas RM, Sala M, Cabré E, et al. Early hospital readmission in decompensated cirrhosis: Incidence, impact on mortality, and predictive factors. Digestive and Liver Disease. 2017 Aug 1;49(8):903–9. Mancuso A, Roblero JP, Riggio O, Celsa C, Calvaruso V, Merli M, et al. Hepatic encephalopathy increases the risk for mortality and hospital readmission in decompensated cirrhotic patients : a prospective multicenter study. Flamm SL. Rifaximin treatment for reduction of risk of overt hepatic encephalopathy recurrence. Therap Adv Gastroenterol. 2011;4(3):199–206. Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology. 2008;48(6):2064–77. Belcher JM, Garcia-tsao G, Sanyal AJ, Bhogal H, Lim JK, Ansari N, et al. Association of AKI With Mortality and Complications in Hospitalized Patients With Cirrhosis. 2012;753–62. Biyik M, Ataseven H, Biyik Z, Asil M, Çifçi S, Sayin S, et al. KDIGO (Kidney Disease: Improving Global Outcomes) criteria as a predictor of hospital mortality in cirrhotic patients. Turkish Journal of Gastroenterology. 2016 Mar 1;27(2):173–9. Ning Y, Zou X, Xu J, Wang X, Ding M, Lu H. Impact of acute kidney injury on the risk of mortality in patients with cirrhosis: a systematic review and meta-analysis. Ren Fail. 2022;44(1):1–14. Fayad L, Narciso-Schiavon JL, Lazzarotto C, Ronsoni MF, Wildner LM, Bazzo ML, et al. The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis. Ann Hepatol. 2015;14(1):83–92. Piotrowski D, Sączewska-Piotrowska A, Jaroszewicz J, Boroń-Kaczmarska A. Predictive power of Model for End-Stage Liver Disease and Child-Turcotte-Pugh score for mortality in cirrhotic patients. Clin Exp Hepatol. 2018;4(4):240–6. Nartey YA, Antwi SO, Bockarie AS, Hiebert L, Njuguna H, Ward JW, et al. Mortality burden due to liver cirrhosis and hepatocellular carcinoma in Ghana; prevalence of risk factors and predictors of poor in-hospital survival. PLoS One [Internet]. 2022;17(9 September):1–16. Available from: http://dx.doi.org/10.1371/journal.pone.0274544 Jonas E, Bernon M, Robertson B, Kassianides C, Keli E, Asare KO, et al. Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions. Lancet Gastroenterol Hepatol. 2022;7(11):1049–60. Poupon R, Carbonell N, Pauwels A, Serfaty L, Fourdan O, L VG. Improved Survival After Variceal Bleeding in Patients With Cirrhosis Over the Past Two Decades ´. 2000; Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4828463","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":334677489,"identity":"fd547937-c6f4-4e82-ab8d-fd0980d9e3f9","order_by":0,"name":"Tamrat Petros Elias","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYPCDCgYGAwiLGacaHjCZAMRsIMYZFC3YtaFqYWwjQos9++m0Dz9/MOTxy/c+fPhzXl2eudjpxA8MFdaJDez9B7DawpO7eWZPAkOxZBu7sTHvtsPFlrNzN0swnElPbOA5jMNhuZsZeBIYEjccY2OTZtx2IHHD7dxtQBceTmyQSMauhf/tZsY/QC37gVokf86pg2r5B9Qi/xi7FonczcxgW9jY2CR4G5ihWhpAtuAIsRtvNzPLpEkUSxxLYzbmOXa42OA20C8Jx9KN23iSDbBpYe/P3cz4xsYmj7/5GOPDHzV1eUAtGz98qLGW7Wc/+ACrNRAgkQBjJcBJNjzqESqRGaNgFIyCUTAKYAAARzxceDJdiboAAAAASUVORK5CYII=","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":true,"prefix":"","firstName":"Tamrat","middleName":"Petros","lastName":"Elias","suffix":""},{"id":334677490,"identity":"7ba3922f-3ec7-49d7-8c66-947cb31fe3e6","order_by":1,"name":"Abate Bane Shewaye","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Abate","middleName":"Bane","lastName":"Shewaye","suffix":""},{"id":334677491,"identity":"600cee90-fc32-4676-bc2b-5a77dd3bbf18","order_by":2,"name":"Henok Fisseha","email":"","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"prefix":"","firstName":"Henok","middleName":"","lastName":"Fisseha","suffix":""},{"id":334677492,"identity":"c9189b29-58a2-4c82-add5-3361af41beb9","order_by":3,"name":"Abdulsemed Mohammed Nur","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Abdulsemed","middleName":"Mohammed","lastName":"Nur","suffix":""},{"id":334677493,"identity":"4ae9cd19-78e6-42c6-8051-8089eaf8bf12","order_by":4,"name":"Kaleb Assefa Berhane","email":"","orcid":"","institution":"Adera Medical and Surgical Center","correspondingAuthor":false,"prefix":"","firstName":"Kaleb","middleName":"Assefa","lastName":"Berhane","suffix":""},{"id":334677494,"identity":"933cf3f9-e07a-47d7-a9a8-6788ed07ee5e","order_by":5,"name":"Asteray Tsige Minyilshewa","email":"","orcid":"","institution":"Adera Medical and Surgical Center","correspondingAuthor":false,"prefix":"","firstName":"Asteray","middleName":"Tsige","lastName":"Minyilshewa","suffix":""},{"id":334677495,"identity":"1a9299dc-300a-4ffc-b1a9-3773a99cb534","order_by":6,"name":"Kibrab Bulto Kumsa","email":"","orcid":"","institution":"St. Paul’s Hospital Millennium Medical College","correspondingAuthor":false,"prefix":"","firstName":"Kibrab","middleName":"Bulto","lastName":"Kumsa","suffix":""},{"id":334677496,"identity":"fa40145d-7475-459e-ad8a-057c80894fb3","order_by":7,"name":"Biruck Mohammed Seid","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Biruck","middleName":"Mohammed","lastName":"Seid","suffix":""}],"badges":[],"createdAt":"2024-07-30 11:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4828463/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4828463/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64172956,"identity":"adc88b86-8758-400d-aec0-b1125ef06ed5","added_by":"auto","created_at":"2024-09-09 11:44:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":611194,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4828463/v1/acc091a2-5c80-49af-97ec-a9e5993b4585.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Predictors of In-hospital Mortality among Cirrhotic Patients in Ethiopia: A Multicenter Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCirrhosis is the fibrotic replacement of liver tissue that can result from any chronic liver disease (CLD) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is a leading cause of liver-related death worldwide. Globally, the estimated number of deaths associated with cirrhosis in 2019 was 1.47\u0026nbsp;million accounting for 2.4% of all-cause mortality. This number increased by 10% after 2010 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the global burden of disease super-regions for 2017, the age-standardized death rate was highest in sub-Saharan Africa [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In Ethiopia, cirrhosis is the 6th leading cause of mortality, accounting for 24 deaths/100,000 population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the initial stages, cirrhosis is compensated and patients are asymptomatic. Decompensation is usually defined as the first occurrence of ascites, esophageal variceal bleeding, or hepatic encephalopathy [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The transition from a compensated state to a decompensated state occurs at a rate of 5\u0026ndash;12% per year [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Once decompensation occurs, the mortality and morbidity resulting from cirrhosis also increase sharply, and the 1-year case-fatality rate can reach 80%. Quality of life is also affected and frequent hospitalizations (admissions and stays) are needed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. When patients with cirrhosis of the liver are hospitalized, mortality increases significantly, ranging from 44 to 74% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe major etiologies of cirrhosis are hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, alcohol-associated liver disease, and metabolic dysfunction-associated steatotic liver disease (MASLD). Globally, among individuals with cirrhosis, 42% had HBV infection and 21% had HCV infection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In sub-Saharan Africa, 69% of liver cirrhosis cases are attributed to HBV, HCV, and alcohol consumption [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hepatitis B virus (40%), alcohol (17%), and hepatitis C virus (15%) are the three most common etiologies of CLD in Ethiopia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Ethiopia, liver disease accounts for 12% of admissions and 31% of hospital mortality in adult medical wards [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. On the other hand, the overall hospital mortality rate in CLD patients ranges from 25\u0026ndash;41% [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the factors affecting in-hospital mortality in admitted liver cirrhosis patients are poorly understood in many regions of Africa including Ethiopia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The few studies conducted in Africa were limited by small sample sizes [\u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This study aimed to assess predictors of in-hospital mortality among cirrhotic patients in a larger sample.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy design\u003c/h2\u003e\n \u003cp\u003eA retrospective cross-sectional study design was used to assess the predictors of in-hospital mortality among patients who were admitted with a diagnosis of liver cirrhosis between January 1, 2023, and March 31, 2024, in the medical wards of Adera Medical Center, St. Paul\u0026rsquo;s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy area\u003c/h2\u003e\n \u003cp\u003eThe study was conducted at Adera Medical Center, St. Paul\u0026rsquo;s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Adera Medical Center is a renowned private health facility in Addis Ababa that provides dedicated gastroenterology and hepatology services for patients from all over the country. St. Paul\u0026rsquo;s Hospital Millennium Medical College is a tertiary-level teaching hospital under the Federal Ministry of Health with more than 700 beds in inpatient capacity. Tikur Anbessa Specialized Hospital is the largest referral university hospital in the country with more than 800 beds.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy participants\u003c/h2\u003e\n \u003cp\u003eAll patients\u0026thinsp;\u0026ge;\u0026thinsp;18 years of age admitted to the medical wards of Adera Medical Center, St. Paul\u0026rsquo;s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital with the diagnosis of liver cirrhosis between January 1, 2023, and March 31, 2024, were included in the study. Exclusion criteria were admission for non-cirrhosis-related causes, multiple missing variables on the patient charts, admission for observation after prophylactic endoscopic variceal ligation or percutaneous liver biopsy, and unknown outcome of treatment due to referral to other centers or discontinuation of treatment against medical advice.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eData collection tools and procedures\u003c/h2\u003e\n \u003cp\u003eSociodemographic (age and sex), clinical (etiology, duration since diagnosis, comorbidity, major signs and symptoms at clinical presentation, history of previous admission within one year, admission diagnosis, prognostic scores at admission, duration of hospital stay, and outcome of hospital admission), laboratory (complete blood count, liver and renal function tests, and electrolytes), and imaging (fibroscan, abdominal ultrasound, computed tomography (CT) scan, and upper gastrointestinal endoscopy) data were extracted from the electronic medical records system between May 1, 2024, and May 31, 2024, by general practitioners working in the health facilities by using a pretested data abstraction format that was prepared by reviewing relevant works of literature. The data quality was ensured through training of the data collectors, close supervision, and prompt feedback. The data were checked for inconsistencies, completeness, accuracy, clarity, coding errors, and missing values, and appropriate corrections were made by the principal investigator.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eSample size and statistical analysis\u003c/h2\u003e\n \u003cp\u003eThe sample size was calculated using Cochran\u0026rsquo;s formula, assuming a mortality rate of 28.4% according to a previous study [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], a 95% confidence interval (CI), and a 5% margin of error (d).\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1724737224.png\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003cp\u003eAfter adding 10% for the probability of having incomplete data, the sample size was found to be 345. A convenient sampling method was used until the desired sample size was achieved.\u003c/p\u003e\n \u003cp\u003eStatistical Package for Social Sciences (SPSS) version 26 was used to enter and analyze the data. Frequency and cross-tabulation are used to summarize the descriptive statistics of the data. Associations between predictor variables and outcomes of interest are estimated using both bivariate analysis and binary logistic regression. The chi-square test and t-test were used in the bivariate analysis. Predictor variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in bivariate analyses are reported and included in the logistic regression. For the binary logistic regression, a 95% confidence interval for adjusted odds ratio (AOR) was calculated and variables with p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eOperational definition\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eLiver cirrhosis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ewas diagnosed based on the presence of two or more of the following\u003c/p\u003e\n \u003cp\u003e\u003cspan\u003e1. Clinical signs of cirrhosis (jaundice, ascites, caput medusa, clubbing, palmar erythema, spider naevi, gynecomastia, female pubic hair pattern, encephalopathy, splenomegaly, or asterixis)\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Impaired liver function test consistent with cirrhosis (International Normalized Ratio (INR)\u0026thinsp;\u0026ge;\u0026thinsp;1.5 and serum albumin\u0026thinsp;\u0026le;\u0026thinsp;3.4gm/dl)\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e3. Imaging diagnosis of cirrhosis ( surface nodularity, coarse and heterogeneous echotexture/ attenuation, segmental atrophy or hypertrophy, ascites, splenomegaly, gall bladder wall thickening, or portal vein diameter\u0026thinsp;\u0026gt;\u0026thinsp;13 mm on abdominal ultrasound and/or CT scan)\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e4. Transient elastography (FibroScan\u003csup\u003e\u0026reg;\u003c/sup\u003e)\u0026thinsp;\u0026gt;\u0026thinsp;12.5 Kilopaskal (KPa)\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e5. AST (aspartate aminotransferase) to Platelet Ratio Index (APRI) score of \u0026ge;\u0026thinsp;1.5 or Fibrosis-4 (FIB-4) score\u0026thinsp;\u0026ge;\u0026thinsp;3.25 [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eEthical consideration\u003c/h2\u003e\n \u003cp\u003eThe study was conducted after obtaining ethical clearance from Adera Medical Center Institutional Review Board (IRB). The IRB of the center waived the need for obtaining informed consent as only anonymized data from participants was collected retrospectively from the electronic medical record system. Confidentiality of individual patient information was maintained by using code numbers instead of other identifiers and the information gained from the chart was used only for research purposes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 356 patients were admitted to the medical wards of the three hospitals with a diagnosis of liver cirrhosis: 236 patients at Adera Medical Center, 71 patients at St. Paul's Hospital Millennium Medical College, and 49 patients at Tikur Anbessa Specialized Hospital. Of the 356 patients, 331 patients fulfilled the inclusion criteria, and 32 patients met the exclusion criteria. Hence, 299 patients were included in the final analysis.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and clinical characteristics\u003c/h2\u003e \u003cp\u003eThe median age of the study participants was 45 (interquartile range (IQR), 36\u0026ndash;56) years and the majority (79.6%) of patients were males. Hepatitis B virus (32.1%) was the most common etiology followed by alcohol (30.1%) and hepatitis C virus (13.4%). The cause of cirrhosis was not identified in 12% of the patients. Metabolic dysfunction-associated steatotic liver disease (MASLD), autoimmune hepatitis, and Budd Chiari syndrome accounted for 7.4%, 6.4%, and 2.3% of the etiology respectively. More than half (52.9%) of the patients were in the Child-Pugh class C category, 35.2% were in class B, and 11.9% were in class A. Approximately one-quarter (26.1%) of the patients had comorbidities. Diabetes (17.1%) was the most common comorbidity followed by hypertension (9.7%). From the signs and symptoms at admission, ascites (69.2%) and fatigue (56.2%) were the most common. Half (50.5%) of the patients presented with upper GI bleeding (UGIB). All patients who presented with UGIB were found to have bleeding esophageal varices on endoscopic evaluation. Hepatic encephalopathy was present in 44.8% of the patients. The encephalopathy was grade one (13.4%), two (55.2%), three (23.9%), and four (7.5%) based on the West Haven criteria. UGIB (27.6%) was the most common precipitant for encephalopathy followed by electrolyte imbalance (23.1%) and spontaneous bacterial peritonitis (SBP) (14.2%). One-fourth (25.8%) of the patients had acute kidney injury (AKI) and 24.8% of the patients had SBP. Hepatocellular carcinoma (HCC) was present in 18.4% of the study participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFactors associated with in-hospital mortality\u003c/h2\u003e \u003cp\u003eOf the 299 patients included in the study, 76 patients (25.4%) have passed away in the hospital. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, factors associated with in-hospital mortality in the bivariate analysis were, age, jaundice, ascites, pedal edema, change in mentation, sleep disturbance, admission within one year, AKI, HCC, hepatic encephalopathy, MELD-Na score, and child-pugh score. From the laboratory parameters, leukocyte count, hemoglobin, AST (aspartate aminotransferase), ALT (alanine aminotransferase), ALP (alkaline phosphatase), bilirubin level, serum albumin, INR (international normalized ratio), creatinine, urea, and serum sodium level have a statistically significant correlation with in-hospital mortality (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate analysis of factors associated with in-hospital mortality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDischarged alive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeath\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian Age in Years (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.0 (35.0\u0026ndash;55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.5 (39.25\u0026ndash;57.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e176 (73.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62 (26.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (77.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (23.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology of cirrhosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis B Virus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e72 (75.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis C Virus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (67.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (32.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMASLD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (90.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutoimmune hepatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (78.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBudd-Chiari Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (69.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (30.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e63 (80.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (19.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e160 (72.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (27.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific comorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (86.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (13.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (79.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma or COPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (90.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSign and Symptom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115 (68.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53 (31.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJaundice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e86 (60.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56 (39.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (70.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (29.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePedal edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66 (61.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (38.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in mentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (51.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (48.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50 (61.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (38.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMelena or hematemesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e123 (84.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (15.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of admission within one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (60.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (39.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e163 (81.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (18.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis at admission\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (70.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (29.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAKI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (42.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (57.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariceal UGIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127 (84.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (15.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatic encephalopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade I or II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66 (71.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade III or IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31 (73.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaboratory Parameters (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeukocyte count\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129.9\u0026thinsp;\u0026plusmn;\u0026thinsp;58.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e279.7\u0026thinsp;\u0026plusmn;\u0026thinsp;68.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84.0\u0026thinsp;\u0026plusmn;\u0026thinsp;61.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176.6\u0026thinsp;\u0026plusmn;\u0026thinsp;77.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e231.9\u0026thinsp;\u0026plusmn;\u0026thinsp;71.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e392.9\u0026thinsp;\u0026plusmn;\u0026thinsp;86.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Bilirubin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum albumin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Sodium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e133.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e128.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum Potassium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean duration of stay in days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean Child-Pugh Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean MELD-Na Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariate analysis was performed by using binary logistic regression to identify associations between variables with a P-value less than 0.05 in the bivariate analysis and in-hospital mortality. A history of previous admission within one year period (AOR: 6.80; 95% CI 2.18\u0026ndash;21.18; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), Grade III or IV hepatic encephalopathy (AOR: 12.0; 95% CI 2.33\u0026ndash;61.63; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), AKI (AOR: 6.47; 95% CI 1.77\u0026ndash;23.64; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), HCC (AOR: 9.05; 95% CI 2.18\u0026ndash;37.14; P: 0.01), and MELD-Na Score (AOR: 1.17; 95% CI 1.05\u0026ndash;1.30; P: 0.02), were found to have a statistically significant association with in-hospital mortality (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCrude and adjusted odds ratio of predictors of In-hospital mortality\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade III or IV HE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2 (3.0\u0026ndash;5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.0 (2.3\u0026ndash;61.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8 (1.2\u0026ndash;2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.0 (2.2\u0026ndash;37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdmission within one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 (1.4\u0026ndash;3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.8 (2.2\u0026ndash;21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAKI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.9 (2.7\u0026ndash;5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.5 (1.7\u0026ndash;23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMELD-Na Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2 (1.1\u0026ndash;1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn Ethiopia, cirrhosis of the liver is the cause of close to one-third of deaths in adult medical wards [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the predictors of in-hospital mortality among cirrhotic patients have not been well-studied. This study aimed to assess these factors in two referral teaching hospitals and one medical center with specialized gastroenterology and hepatology services. A total of 356 cirrhotic patients were admitted to the three health facilities during the study period, of which, 299 patients fulfilled the inclusion criteria and were included in the final analysis. The majority (79.6%) of patients were males. The median age of the study participants was 45 (IQR, 36\u0026ndash;56) years and Hepatitis B virus (32.1%) was the most common etiology. More than half (52.9%) of the patients were in the Child-Pugh class C category. The prevalence of in-hospital mortality was 25.4%. In the binary logistic regression, history of previous admission within one one-year period, Grade III or IV hepatic encephalopathy, AKI, HCC, and MELD-Na Score were found to be significantly associated with in-hospital mortality.\u003c/p\u003e \u003cp\u003eThe median age of the patients admitted to the hospitals was 45 (IQR, 36\u0026ndash;56) years. This relatively young age is concerning, as cirrhosis can significantly impact patients' quality of life and life expectancy. This can have major socioeconomic consequences and can lead to disability, lost productivity, and the need for significant medical care and support. A similar age group was reported in Ethiopia [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and other African studies [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, this age is lower than those found in previous US [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and European [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] research. This could be because of the high viral hepatitis burden and a limited access to quality healthcare and liver disease screening in many African settings which can lead to delayed diagnoses, allowing earlier stages of hepatitis to progress further before patients receive appropriate management.\u003c/p\u003e \u003cp\u003eThe majority (79.6%) of the patients in this study were males. A higher prevalence of cirrhosis in males was reported in multiple other studies [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The higher prevalence of liver cirrhosis and its complications in men is likely due to a combination of behavioral factors such as alcohol consumption, and biological factors such as lower levels of estrogen, which have been shown to have anti-fibrotic and anti-inflammatory effects on the liver that collectively increase their susceptibility to the development and progression of various liver diseases leading to cirrhosis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the most common etiology was hepatitis B virus (32.1%) followed by alcohol (30.1%) and hepatitis C virus (13.4%). HBV was also reported as the leading cause of cirrhosis in other studies conducted in Ethiopia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Similar results were observed in research done in Togo [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], Ghana [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], Nigeria [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and other Sub-Saharan African countries [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. HCV is the major cause of cirrhosis in the Eastern Mediterranean region[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and North Africa [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Alcohol was the dominant etiology in reports from India [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Thailand [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and Colombia[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although lower than the global average, the peculiar finding in our study, when compared to other similar studies in Ethiopia, is the increasing prevalence of alcohol related liver disease and MASLD. This can be linked to the increasing trends in hazardous alcohol consumption[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and metabolic risk factors for MASLD such as diabetes[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] in Ethiopia. This was also evident in our study, which revealed that 17.1% of the patients had diabetes and 26.1% of the patients had comorbidities. This represents a substantial change from an earlier Ethiopian study that reported the prevalence of diabetes and comorbidities in general to be 6.4% and 11% respectively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This finding aligns with the global pattern that indicates the impending eclipse of the influence of viral hepatitis by emergent metabolic CLDs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAscites (69.2%), UGIB (50.5%), and hepatic encephalopathy (44.8%) were the most common presentations in this study. This finding significantly differs from those of former studies conducted in Ethiopia which reported UGIB to be present in 10.2% and 25.7% of the cases [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The figure in our study is also higher than those reported by researchers from the United States (8.6%), Madagascar (33.3%), and Colombia (17.3%) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The primary reason for this is that patients are usually referred to these centers for therapeutic endoscopic interventions due to the restricted availability of these services at other hospitals. The most frequent precipitant of hepatic encephalopathy in our patients was likewise discovered to be UGIB, which may account for why our study's prevalence of hepatic encephalopathy was higher than that of previous investigations.\u003c/p\u003e \u003cp\u003eIn this study, the in-hospital mortality rate was 25.4%. This is comparable with the 25.9% and 23.5% in-hospital mortality rates that have been reported from studies previously conducted in Madagascar and Colombia, respectively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, this percentage was less than that reported by studies carried out in Saudi Arabia (35%), Ghana (41.9%), and the Ivory Coast (42.2%) and much greater than that reported in Pakistan (15.7%), Morocco (8.7%), and the US (6.6%). These discrepancies may have resulted from variances in the study settings, as the study in Saudi Arabia included patients admitted to the ICU, and the baseline characteristics of the patients. These attributes include the stage of the disease, related comorbidities, specific complications of liver cirrhosis that resulted in hospitalization, and the clinical condition of the patients at admission. The higher mortality rate seen in the current study compared to that of the US, Pakistan, and Morocco can also be attributed to patients' delayed presentations and the lack of treatment options, such as shunt surgeries, which serve as a bridge to more definitive options such as liver transplantation nationwide.\u003c/p\u003e \u003cp\u003eHepatic encephalopathy is one of the most common complications of liver cirrhosis and results in a spectrum of neuropsychiatric symptoms caused by circulating gut-derived toxins of nitrogenous compounds. West Haven Grade III or IV hepatic encephalopathy was found to be an independent predictor of in-hospital mortality. Multiple similar findings were reported from Ghana, Morocco, Madagascar, and the United States [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This underlines the need for prompt identification of hepatic encephalopathy and its precipitant at an earlier stage, followed by proper management.\u003c/p\u003e \u003cp\u003eHistory of previous admission within one year was 33.1% and was also found to be a predictor of in-hospital mortality in the logistic regression. A similar finding was reported in Spain and Canada [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. One possible explanation for the greater death rate in our patients with a history of readmission could be the substantially greater prevalence of hepatic encephalopathy (59.6% vs. 37.5%) in this group of patients than in the patients without such a history. Hepatic encephalopathy was also found to increase readmission and mortality in a study conducted in Italy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This may also be exacerbated by the unavailability of rifaximin in Ethiopia, which has been demonstrated to lower the risk of overt hepatic encephalopathy recurrence [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with cirrhosis may have acute kidney damage (AKI) for a variety of reasons. Some of these include hepatorenal syndrome (HRS), which is characterized by renal vasoconstriction secondary to splanchnic pooling of blood that reduces the effective circulating blood volume; decreased renal perfusion due to gastrointestinal bleeding; use of diuretics; diarrhea caused by the use of lactulose or infections; and so on [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Regardless of the etiology, AKI was associated with increased in-hospital mortality in our study, which is similar to the findings of studies in the United States and Turkey [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This was also demonstrated in another systematic review and meta-analysis [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe MELD Na score was also found to be an independent predictor of in-hospital mortality in our study. Similar studies performed in Brazil, and Poland also showed that the MELD Na score predicts in-hospital mortality in cirrhotic patients [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHCC was the other predictor of hospital mortality in this study. Similar findings were reported in other Sub-Saharan African countries such as Ivory Coast and Ghana [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, the presence of HCC was not found to be a predictor of in-hospital mortality in research done in the US [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Because of poor screening and surveillance of HCC in cirrhotic patients, 95% of HCC cases in Sub-Saharan Africa are diagnosed late in the advanced or terminal stages, whereas 40% of cases in high-income countries are diagnosed at an early stage [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. This, combined with the very limited availability of curative therapies, may have contributed to the results observed in our study.\u003c/p\u003e \u003cp\u003eUGIB was not shown to predict in-hospital mortality. The literature shows mixed results on the effect of UGIB on in-hospital mortality. A previous study done in Ethiopia [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and another study conducted in Ghana [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] showed a significant association. In contrast, a study from France [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] showed a different result. Endoscopic therapy and antibiotic prophylaxis were shown to be independent predictors of survival in the French study. The reduced mortality found in our study could be due to the relatively better availability of interventional endoscopic services in the centers where our research was conducted, coupled with the current standard use of short-term antibiotic prophylaxis for SBP.\u003c/p\u003e \u003cp\u003eThe major limitation of our study emanates from its retrospective design. The information collected from the electronic medical records included medical history, physical examination, and laboratory and imaging investigations ordered and documented by the treating physicians. This led us to remove some important parameters, such as nutritional status assessment with body mass index, from our study because these parameters were not available in almost all of the patient files. A significant number of patients were also excluded from the study because of multiple missing variables in their workups.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, in-hospital mortality in cirrhotic patients is high in Ethiopia. West Haven grade III or IV hepatic encephalopathy, History of previous admission within one year period, AKI, HCC, and MELD-Na Score, were found to be predictors of in-hospital mortality. Prompt identification and management of hepatic encephalopathy and its precipitant at an earlier stage is crucial. Routine screening for HCC in patients with cirrhosis is also important for diagnosing and treating the disease at an earlier stage. Patients with a history of admission within a year, AKI, and high MELD Na score also need closer follow-up for a better treatment outcome and survival.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMELD-Na: Model for End-Stage Liver Disease \u0026ndash; Sodium\u003c/p\u003e\n\u003cp\u003eCLD: Chronic liver disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHBV: Hepatitis B Virus\u003c/p\u003e\n\u003cp\u003eHCV: Hepatitis C Virus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMASLD: Metabolic dysfunction associated steatotic liver disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCT: Computed tomography\u003c/p\u003e\n\u003cp\u003eAST: Aspartate aminotransferase\u003c/p\u003e\n\u003cp\u003eALT: Alanine aminotransferase\u003c/p\u003e\n\u003cp\u003eALP: Alkaline phosphatase\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPRI: Aspartate aminotransferase to platelet ratio index\u003c/p\u003e\n\u003cp\u003eKPa: Kilopascal\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFIB-4: Fibrosis-4\u003c/p\u003e\n\u003cp\u003eUGIB: Upper gastrointestinal bleeding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSBP: Spontaneous bacterial peritonitis\u003c/p\u003e\n\u003cp\u003eAKI: Acute kidney injury\u003c/p\u003e\n\u003cp\u003eHCC: Hepatocellular carcinoma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eINR: International normalized ratio\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was obtained from the institutional review board of Adera medical and surgical center, Ref No: 087/24. The IRB of the center waived the need for obtaining informed consent as only anonymized data from participants was collected retrospectively from the electronic medical record system. Confidentiality of individual patient information was maintained by using code numbers instead of other identifiers and the information gained from the chart was used only for research purposes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study received no funding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contribution\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTE, AS, and AN initiated the concept of the study. TE, AS, AM, and KB are involved in the study design. TE, KB, AM, KK, and BS are involved in data acquisition. TE, KB, and HF are involved in data interpretation. TE, AS, HF, and AN are involved in manuscript writing. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to extend our sincere gratitude to the management and staff of Adera medical and surgical center, St. Paul\u0026rsquo;s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital for their support and cooperation throughout the duration of this study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTapper EB, Parikh ND. Diagnosis and Management of Cirrhosis and Its Complications: A Review. Vol. 329, JAMA. 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Ethiopian Journal of Health Development. 2023;37(Special Issue 2):1\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eBuganza-Torio E, Montano-Loza AJ. Hospital mortality in cirrhotic patients at a tertiary care center in Latin America. Revista de Gastroenterolog\u0026iacute;a de M\u0026eacute;xico (English Edition). 2017 Jul;82(3):201\u0026ndash;2. \u003c/li\u003e\n\u003cli\u003eMokdad AA, Lopez AD, Shahraz S, Lozano R, Mokdad AH, Stanaway J, et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: A systematic analysis. BMC Med. 2014 Sep 18;12(1). \u003c/li\u003e\n\u003cli\u003eTesfaye BT, Feyissa TM, Workneh AB, Gudina EK, Yizengaw MA. Chronic Liver Disease in Ethiopia with a Particular Focus on the Etiological Spectrums: A Systematic Review and Meta-Analysis of Observational Studies. Vol. 2021, Canadian Journal of Gastroenterology and Hepatology. Hindawi Limited; 2021. \u003c/li\u003e\n\u003cli\u003eBelyhun Y, Maier M, Mulu A, Diro E, Liebert UG. Hepatitis viruses in Ethiopia: A systematic review and meta-analysis. BMC Infect Dis. 2016 Dec 19;16(1). \u003c/li\u003e\n\u003cli\u003eAdhanom M, Desalegn H. MAGNITUDE, CLINICAL PROFILE AND HOSPITAL OUTCOME OF CHRONIC LIVER DISEASE AT ST. PAUL\u0026rsquo;S HOSPITAL MILLENNIUM MEDICAL COLLEGE, ADDIS ABABA, ETHIOPIA [Internet]. Vol. 55, Ethiop Med J. 2017. Available from: https://www.researchgate.net/publication/320225040\u003c/li\u003e\n\u003cli\u003eTesfaye BT, Gudina EK, Bosho DD, Mega TA. Short-term clinical outcomes of patients admitted with chronic liver disease to selected teaching hospitals in Ethiopia. PLoS One. 2019 Aug 1;14(8). \u003c/li\u003e\n\u003cli\u003eRazafindrazoto CI, Randriamifidy NH, Ralaizanaka BM, Andrianoelison JT, Ravelomanantsoa HT, Rakotomaharo M, et al. Factors Associated with in-Hospital Mortality in Malagasy Patients with Acute Decompensation of Liver Cirrhosis: A Retrospective Cohort. Hepat Med. 2023 Mar;Volume 15:21\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eDuah A, Agyei-Nkansah A, Osei-Poku F, Duah F, Addo BP. Sociodemographic characteristics, complications requiring hospital admission and causes of in-hospital death in patients with liver cirrhosis admitted at a district hospital in Ghana. PLoS One. 2021 Jun 1;16(6 June). \u003c/li\u003e\n\u003cli\u003eOkon JB, Diakite M, Ake F, Kouadio OK, Kone A. Mortality Factors for Cirrhotics in an Ivorian University Hospital (Ivory Coast). Open J Gastroenterol. 2020;10(09):231\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eMellinger JL, Richardson CR, Mathur AK, Volk ML. Variation among United States hospitals in inpatient mortality for cirrhosis. Clinical Gastroenterology and Hepatology. 2015 Mar 1;13(3):577\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eRiggio O, Celsa C, Calvaruso V, Merli M, Caraceni P, Montagnese S, et al. Hepatic encephalopathy increases the risk for mortality and hospital readmission in decompensated cirrhotic patients: a prospective multicenter study. Front Med (Lausanne). 2023;10. \u003c/li\u003e\n\u003cli\u003eZubieta-Rodr\u0026iacute;guez R, G\u0026oacute;mez-Correa J, Rodr\u0026iacute;guez-Amaya R, Ariza-Mejia KA, Toloza-Cuta NA. Hospital mortality in cirrhotic patients at a tertiary care center. Revista de Gastroenterolog\u0026iacute;a de M\u0026eacute;xico (English Edition). 2017 Jul;82(3):203\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eJun BG, Lee WC, Jang JY, Jeong SW, Kim YD, Cheon GJ, et al. Follow-up creatinine level is an important predictive factor of in-hospital mortality in cirrhotic patients with spontaneous bacterial peritonitis. J Korean Med Sci. 2018 Mar 19;33(12). \u003c/li\u003e\n\u003cli\u003eBal CK, Daman R, Bhatia V. Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis. World J Hepatol. 2016 Apr 28;8(12):566\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eRubin JB, Sundaram V, Lai JC. Gender Differences among Patients Hospitalized with Cirrhosis in the United States. J Clin Gastroenterol. 2020 Jan 1;54(1):83\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBagny A, Bouglouga O, Lawson-Ananissoh LM, Dusabe A, Kaaga YL, Balaka A, et al. Quality of Life of the Patients Suffering from Chronic Liver Diseases at the University Health Center Campus of Lome. Open J Gastroenterol. 2015;05(07):88\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eOfori-Asenso R, Agyeman AA. Hepatitis B in Ghana: A systematic review \u0026amp; meta-analysis of prevalence studies (1995-2015). BMC Infect Dis. 2016;16(1). \u003c/li\u003e\n\u003cli\u003eAdekanle O, Ijarotimi O, Obasi E, Anthony-Nwojo N, Ndububa D. A Southwest Nigerian tertiary hospital 5-year study of the pattern of liver disease admission. NIGERIAN JOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY. 2020;12(1):18. \u003c/li\u003e\n\u003cli\u003eSpearman CW, Sonderup MW. Health disparities in liver disease in sub-Saharan Africa. Vol. 35, Liver International. Blackwell Publishing Ltd; 2015. p. 2063\u0026ndash;71. \u003c/li\u003e\n\u003cli\u003eSamonakis DN, Koulentaki M, Coucoutsi C, Augoustaki A, Baritaki C, Digenakis E, et al. Clinical outcomes of compensated and decompensated cirrhosis: A long term study. World J Hepatol. 2014;6(7):504\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eCharif I, Saada K, Mellouki I, El Yousfi M, Benajah D, El Abkari M, et al. Predictors of Intra-Hospital Mortality in Patients with Cirrhosis. Open J Gastroenterol. 2014;04(03):141\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eAbd-Elrazek MM, El-Gharabawy NM, Atlam SA, Gabr MA. Clinical Characteristics and Etiology of Chronic Liver Disease among Egyptian Patients in Nile Delta: A Clinical Study. Int J Trop Dis Health. 2022 Aug 9;25\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003eKudru CU, Eshwara VK, Nagiri SK, Guddattu V. Spectrum of bacterial infections and predictors of mortality in adult cirrhotic patients. Med Pharm Rep. 2019;92(4):356\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eBunchorntavakul C, Hospital R, Charoen A. Nutritional status and its impact on clinical outcomes for patients admitted to Hospital with Cirrhosis [Internet]. 2016. Available from: https://www.researchgate.net/publication/302416910\u003c/li\u003e\n\u003cli\u003eAyano G, Yohannis K, Abraha M, Duko B. The epidemiology of alcohol consumption in Ethiopia: A systematic review and meta-analysis. Vol. 14, Substance Abuse: Treatment, Prevention, and Policy. BioMed Central Ltd.; 2019. \u003c/li\u003e\n\u003cli\u003eAnimaw W, Seyoum Y. Increasing prevalence of diabetes mellitus in a developing country and its related factors. PLoS One. 2017 Nov 1;12(11). \u003c/li\u003e\n\u003cli\u003eDuah A, Agyei-nkansah A, Osei-poku F, Duah F, Ampofo-boobi D, Peprah B. The Prevalence , Predictors , and In-Hospital Mortality of Hepatic Encephalopathy in Patients with Liver Cirrhosis Admitted at St . Dominic Hospital in Akwatia , Ghana. 2020;2020. \u003c/li\u003e\n\u003cli\u003eBajaj JS, O\u0026rsquo;Leary JG, Tandon P, Wong F, Garcia-Tsao G, Kamath PS, et al. Hepatic Encephalopathy Is Associated With Mortality in Patients With Cirrhosis Independent of Other Extrahepatic Organ Failures. Clinical Gastroenterology and Hepatology. 2017 Apr 1;15(4):565-574.e4. \u003c/li\u003e\n\u003cli\u003eBhsc JMM, Dewit Y, Groome P, Djerboua M, Booth CM, Flemming JA. Early hospital readmission and survival in patients with cirrhosis : A population-based study. \u003c/li\u003e\n\u003cli\u003eMorales BP, Planas R, Bartoli R, Morillas RM, Sala M, Cabr\u0026eacute; E, et al. Early hospital readmission in decompensated cirrhosis: Incidence, impact on mortality, and predictive factors. Digestive and Liver Disease. 2017 Aug 1;49(8):903\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMancuso A, Roblero JP, Riggio O, Celsa C, Calvaruso V, Merli M, et al. Hepatic encephalopathy increases the risk for mortality and hospital readmission in decompensated cirrhotic patients : a prospective multicenter study. \u003c/li\u003e\n\u003cli\u003eFlamm SL. Rifaximin treatment for reduction of risk of overt hepatic encephalopathy recurrence. Therap Adv Gastroenterol. 2011;4(3):199\u0026ndash;206. \u003c/li\u003e\n\u003cli\u003eGarcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology. 2008;48(6):2064\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eBelcher JM, Garcia-tsao G, Sanyal AJ, Bhogal H, Lim JK, Ansari N, et al. Association of AKI With Mortality and Complications in Hospitalized Patients With Cirrhosis. 2012;753\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eBiyik M, Ataseven H, Biyik Z, Asil M, \u0026Ccedil;if\u0026ccedil;i S, Sayin S, et al. KDIGO (Kidney Disease: Improving Global Outcomes) criteria as a predictor of hospital mortality in cirrhotic patients. Turkish Journal of Gastroenterology. 2016 Mar 1;27(2):173\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eNing Y, Zou X, Xu J, Wang X, Ding M, Lu H. Impact of acute kidney injury on the risk of mortality in patients with cirrhosis: a systematic review and meta-analysis. Ren Fail. 2022;44(1):1\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eFayad L, Narciso-Schiavon JL, Lazzarotto C, Ronsoni MF, Wildner LM, Bazzo ML, et al. The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis. Ann Hepatol. 2015;14(1):83\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003ePiotrowski D, Sączewska-Piotrowska A, Jaroszewicz J, Boroń-Kaczmarska A. Predictive power of Model for End-Stage Liver Disease and Child-Turcotte-Pugh score for mortality in cirrhotic patients. Clin Exp Hepatol. 2018;4(4):240\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eNartey YA, Antwi SO, Bockarie AS, Hiebert L, Njuguna H, Ward JW, et al. Mortality burden due to liver cirrhosis and hepatocellular carcinoma in Ghana; prevalence of risk factors and predictors of poor in-hospital survival. PLoS One [Internet]. 2022;17(9 September):1\u0026ndash;16. Available from: http://dx.doi.org/10.1371/journal.pone.0274544\u003c/li\u003e\n\u003cli\u003eJonas E, Bernon M, Robertson B, Kassianides C, Keli E, Asare KO, et al. Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions. Lancet Gastroenterol Hepatol. 2022;7(11):1049\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003ePoupon R, Carbonell N, Pauwels A, Serfaty L, Fourdan O, L VG. Improved Survival After Variceal Bleeding in Patients With Cirrhosis Over the Past Two Decades \u0026acute;. 2000; \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cirrhosis, In-hospital mortality, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4828463/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4828463/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCirrhosis is a major global health problem and a leading cause of liver-related mortality. In Ethiopia specifically, cirrhosis is the 6th leading cause of death and is responsible for high hospitalization and mortality rates. However, until now, factors affecting in-hospital mortality in patients admitted due to complications of liver cirrhosis are poorly understood. This study assessed the predictors of in-hospital mortality among cirrhotic patients in Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cross-sectional study using data collected from the electronic medical records of patients who were admitted for complications of liver cirrhosis between January 1, 2023, and March 31, 2024, in the medical wards of Adera Medical Center, St. Paul\u0026rsquo;s Hospital Millennium Medical College, and Tikur Anbessa Specialized Hospital. Frequency and cross-tabulation were used for descriptive statistics. Predictor variables with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in bivariate analyses were included in the logistic regression. The adjusted odds ratio (AOR) with the corresponding 95% confidence interval (CI) was calculated to show the strength of the association. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 299 patients included in the final analysis, the majority (79.6%) were males, and the median age of the study participants was 45 (IQR, 36\u0026ndash;56) years. Hepatitis B virus (32.1%) was the most common etiology, followed by alcohol (30.1%) and hepatitis C virus (13.4%). More than half (52.9%) of the patients were in Child-Pugh class C, and around a quarter (26.1%) of the patients had comorbidities. Ascites (69.2%), Upper gastrointestinal bleeding (50.5%), and hepatic encephalopathy (44.8%) were the most common forms of presentation. The in-hospital mortality rate was 25.4%. West Haven Grade III or IV hepatic encephalopathy (AOR: 12.0; 95% CI 2.33\u0026ndash;61.63; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), Hepatocellular Carcinoma (AOR: 9.05; 95% CI 2.18\u0026ndash;37.14; P: 0.01), History of previous admission within one year period (AOR: 6.80; 95% CI 2.18\u0026ndash;21.18; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), Acute Kidney Injury (AOR: 6.47; 95% CI 1.77\u0026ndash;23.64; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and Model for End-Stage Liver Disease \u0026ndash; Sodium (MELD-Na) Score (AOR: 1.17; 95% CI 1.05\u0026ndash;1.30; P: 0.02), were found to be predictors of in-hospital mortality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn-hospital mortality of cirrhotic patients is high in Ethiopia. West Haven grade III or IV hepatic encephalopathy is the leading cause of mortality. Hence, Prompt identification and management of hepatic encephalopathy and its precipitant at an earlier stage is crucial for better treatment outcomes and survival.\u003c/p\u003e","manuscriptTitle":"Predictors of In-hospital Mortality among Cirrhotic Patients in Ethiopia: A Multicenter Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 05:44:55","doi":"10.21203/rs.3.rs-4828463/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3048ab54-ce43-42a2-928c-6274b51c348f","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-09T11:36:03+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-27 05:44:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4828463","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4828463","identity":"rs-4828463","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}