Low haemoglobin level predicts early hospital readmission in patients with cirrhosis and acute decompensation

Abstract

Background & aims: Patients with decompensated cirrhosis present frequent hospitalisations with a relevant clinical and socio-economic impact. This study aims to characterise unscheduled readmissions up to 1-year follow-up and identify predictors of 30-day readmission after an index hospitalisation for acute decompensation (AD).

Methods: We performed a secondary analysis of a prospectively collected cohort of patients admitted for AD. Laboratory and clinical data at admission and at discharge were collected. Timing and causes of unscheduled readmissions and mortality were recorded up to 1 year.

Results: A total of 329 patients with AD were included in the analysis. Acute-on-chronic liver failure was diagnosed in 19% of patients at admission or developed in an additional 9% of patients during the index hospitalisation. During the 1-year follow-up, 182 patients (55%) were rehospitalised and 98 (30%) more than once. The most frequent causes of readmission were hepatic encephalopathy (36%), ascites (22%), and infection (21%). Cumulative incidence of readmission was 20% at 30 days, 39% at 90 days, and 63% at 1 year. Fifty-four patients were readmitted for emergent liver-related causes within 30 days. Early readmission was associated with a higher 1-year mortality (47 vs. 32%, p = 0.037). Multivariable Cox regression analysis showed that haemoglobin (Hb) ≤8.7 g/dl (hazard ratio 2.63 [95% CI 1.38-5.02], p = 0.003) and model for end-stage liver disease-sodium score (MELD-Na) >16 at discharge (hazard ratio 2.23 [95% CI 1.27-3.93], p = 0.005), were independent predictors of early readmission. In patients with MELD-Na >16 at discharge, the presence of Hb ≤8.7 g/dl doubles the risk of early rehospitalisation (44% vs. 22%, p = 0.02).

Conclusion: Besides MELD-Na, a low Hb level (Hb ≤8.7 g/dl) at discharge emerged as a new risk factor for early readmission, contributing to identification of patients who require closer surveillance after discharge.

Impact and implications: Patients with decompensated cirrhosis face frequent hospitalisations. In the present study, type and causes of readmissions were analysed during 1-year follow-up in patients discharged after the index hospitalisation for an acute decompensation of the disease. Early (30-day) liver-related readmission was associated with higher 1-year mortality. The model for end-stage liver disease-sodium score and low haemoglobin at discharge were identified as independent risk factors for early readmissions. Haemoglobin emerged as a new easy-to-use parameter associated with early readmission warranting further investigation.

Keywords: Anaemia; Early readmission; Haemoglobin; Hospitalisation; Liver cirrhosis; MELD score; Systemic inflammation.

Graphical abstract

Fig. 1

Flow chart of the study.

Fig. 2

Number of readmissions and cumulative incidence of readmissions during the follow-up period. (A) Number of patients with one, two, three, or four or more readmissions during the follow-up period. (B) Kaplan-Meier estimate of the cumulative incidence of all cause readmissions during follow-up (purple line, death and transplant considered as censoring events) and cumulative incidence of all cause readmission or death (green line, transplant considered as censoring event).

Fig. 3

Cumulative incidence of liver-related early readmissions and cumulative incidence of death during the follow-up period. (A) Thirty-day cumulative incidence of liver-related early readmissions. (B) Cumulative incidence function of mortality considering liver transplantation as a competing event in patients readmitted within 30 days (early readmission) for liver-related causes as compared with those not early readmitted. The cumulative incidence was compared using Gray's test.

Fig. 4

Cumulative incidence of liver-related early readmissions according to the presence of the risk factors identified in the analyses. (A) Thirty-day cumulative incidence of liver-related early readmissions in patients presenting none, one, or two of the following independent risk factors: Hb ≤8.7 g/dl and MELD-Na >16 at discharge of the index hospitalisation. (B) Thirty-day cumulative incidence of liver-related early readmissions in patients with MELD-Na >16 presenting a Hb level of at least or lower than 8.7 g/dl at discharge. Comparisons were made using the log-rank test. Hb, haemoglobin; MELD-Na, model for end-stage liver disease-sodium.