Mortality Risk and Decompensation in Hospitalized Patients with Non-Alcoholic Liver Cirrhosis: Implications for Disease Management
Abstract
:1. Introduction
2. Materials and Methods
2.1. Data Source and Study Design
2.2. Primary Outcome
2.3. Statistical Aanalysis
2.4. Subgroup Analysis
2.5. Ethical Considerations
3. Results
3.1. Baseline Characteristics of the Study Cohorts
3.2. Excess Mortality Risk from Decompensation
3.3. Adjusted Mortality Risk in Patient Subgroups
4. Discussion
4.1. Main Findings
4.2. Comparison with Other Studies
4.3. Strengths and Limitations
4.4. Implications on Disease Management
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Asrani, S.K.; Devarbhavi, H.; Eaton, J.; Kamath, P.S. Burden of liver diseases in the world. J. Hepatol. 2019, 70, 151–171. [Google Scholar] [CrossRef] [PubMed]
- Wong, M.C.S.; Huang, J.L.W.; George, J.; Huang, J.; Leung, C.; Eslam, M.; Chan, H.L.-Y.; Ng, S.C. The changing epidemiology of liver diseases in the Asia–Pacific region. Nat. Rev. Gastroenterol. Hepatol. 2019, 16, 57–73. [Google Scholar] [CrossRef] [PubMed]
- Chiang, C.; Yang, Y.; Chen, J.; You, S.; Yang, H.; Lee, M.; Lai, M.; Chen, C. Significant reduction in end-stage liver diseases burden through the national viral hep-atitis therapy program in Taiwan. Hepatology 2015, 61, 1154–1162. [Google Scholar] [CrossRef] [PubMed]
- Hsu, C.-S.; Kao, J.-H. Non-alcoholic fatty liver disease: An emerging liver disease in Taiwan. J. Formos. Med. Assoc. 2012, 111, 527–535. [Google Scholar] [CrossRef] [Green Version]
- Ratib, S.; Fleming, K.M.; Crooks, C.J.; Aithal, G.P.; West, J. 1 and 5 year survival estimates for people with cirrhosis of the liver in England, 1998–2009: A large population study. J. Hepatol. 2014, 60, 282–289. [Google Scholar] [CrossRef] [Green Version]
- A Mokdad, A.; Lopez, A.D.; Shahraz, S.; Lozano-Ascencio, R.; Stanaway, J.; Murray, C.; Naghavi, M. Liver cirrhosis mortality in 187 countries between 1980 and 2010: A systematic analysis. BMC Med. 2014, 12, 145. [Google Scholar] [CrossRef] [Green Version]
- Su, T.-H.; Hu, T.-H.; Chen, C.-L.; Huang, Y.-H.; Chuang, W.-L.; Lin, C.-C.; Wang, C.-C.; Su, W.-W.; Chen, M.-Y.; Peng, C.-Y.; et al. Four-year entecavir therapy reduces hepatocellular carcinoma, cirrhotic events and mortality in chronic hepatitis B patients. Liver Int. 2016, 36, 1755–1764. [Google Scholar] [CrossRef]
- Morsy, K.H.; Mekky, M.A.; Abdel-Malek, M.O.; Abbas, W.A. Incidence, causes, and outcomes of renal failure among cirrhotic patients. Turk. J. Gastroenterol. 2015, 26, 517–521. [Google Scholar] [CrossRef]
- Tsai, C.-F.; Chu, C.-J.; Huang, Y.-H.; Wang, Y.; Liu, P.-Y.; Lin, H.-C.; Lee, F.-Y.; Lu, C.-L. Detecting Minimal Hepatic Encephalopathy in an Endemic Country for Hepatitis B: The Role of Psychometrics and Serum IL-6. PLoS ONE 2015, 10, e0128437. [Google Scholar] [CrossRef]
- Hung, T.-H.; Liang, C.-M.; Hsu, C.-N.; Tai, W.-C.; Tsai, K.-L.; Ku, M.-K.; Wang, J.-W.; Tseng, K.-L.; Yuan, L.-T.; Nguang, S.-H.; et al. Association between complicated liver cirrhosis and the risk of hepatocellular carcinoma in Taiwan. PLoS ONE 2017, 12, e0181858. [Google Scholar] [CrossRef] [PubMed]
- Dienstag, J.L. Part 10 Disorders of the Gastrointestinal System, Section 3 Liver and Biliary Tract Diseases, 334 Chronic Hepati-tis. In Harrison’s Principles of Internal Medicine, 20th ed.; Jameson, J.L., Fauci, A.S., Kasper, D.L., Eds.; McGraw-Hill Education: New York, NY, USA, 2018; Volume 1, pp. 2375–2399. [Google Scholar]
- Ratib, S.; Fleming, K.M.; Crooks, C.J.; Walker, A.J.; West, J. Causes of Death in People with Liver Cirrhosis in England Compared with the General Population: A Population-Based Cohort Study. Am. J. Gastroenterol. 2015, 110, 1149–1158. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Tapper, E.B.; Parikh, N.D. Mortality due to cirrhosis and liver cancer in the United States, 1999–2016: Observational study. BMJ 2018, 362, k2817. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Orman, E.S.; Roberts, A.; Ghabril, M.; Nephew, L.; Desai, A.; Patidar, K.; Chalasani, N. Trends in characteristics, mortality, and other outcomes of patients with newly diag-nosed cirrhosis. JAMA Netw. Open 2019, 2, e196412. [Google Scholar] [CrossRef] [PubMed]
- Roberts, S.E.; Goldacre, M.J.; Yeates, D. Trends in mortality after hospital admission for liver cirrhosis in an English population from 1968 to 1999. Gut 2005, 54, 1615–1621. [Google Scholar] [CrossRef]
- Sørensen, H.T.; Thulstrup, A.M.; Mellemkjar, L.; Jepsen, P.; Christensen, E.; Olsen, J.H.; Vilstrup, H. Long-term survival and cause-specific mortality in patients with cirrhosis of the liver: A nationwide cohort study in Denmark. J. Clin. Epidemiol. 2003, 56, 88–93. [Google Scholar] [CrossRef]
- Fong, T.L.; di Bisceglie, A.M.; Waggoner, J.G.; Banks, S.M.; Hoofnagle, J.H. The significance of antibody to hepatitis C virus in patients with chronic hepa-titis B. Hepatology 1991, 14, 64–67. [Google Scholar] [CrossRef]
- Crespo, J.; Lozano, J.L.; De La Cruz, F.; Rodrigo, L.; Rodríguez, M.; Miguel, G.S.; Artiñano, E.; Pons-Romero, F. Prevalence and significance of hepatitis C viremia in chronic active hepatitis B. Am. J. Gastroenterol. 1994, 89, 1147–1151. [Google Scholar]
- Donato, F.; Boffetta, P.; Puoti, M. A meta-analysis of epidemiological studies on the combined effect of hepatitis B and C virus infections in causing hepatocellular carcinoma. Int. J. Cancer 1998, 75, 347–354. [Google Scholar] [CrossRef]
- Li, J.; Zou, B.; Yeo, Y.H.; Feng, Y.; Xie, X.; Lee, D.H.; Fujii, H.; Wu, Y.; Kam, L.Y.; Ji, F.; et al. Prevalence, incidence, and outcome of non-alcoholic fatty liver disease in Asia, 1999–2019: A systematic review and meta-analysis. Lancet Gastroenterol. Hepatol. 2019, 4, 389–398. [Google Scholar] [CrossRef]
- Maitra, T.; Adhikari, A.K. A clinical study of the spectrum of complications of cirrhosis. Assam J. Intern. Med. 2013, 3, 18–21. [Google Scholar]
- Chung, W.; Jo, C.; Chung, W.J.; Kim, D.J. Liver cirrhosis and cancer: Comparison of mortality. Hepatol. Int. 2018, 12, 269–276. [Google Scholar] [CrossRef] [PubMed]
- Garcia-Tsao, G.; Friedman, S.L.; Iredale, J.; Pinzani, M. Now there are many (stages) where before there was one: In search of a pathophysiological classification of cirrhosis. Hepatology 2009, 51, 1445–1449. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Sharara, A.I.; Rockey, D.C. Gastroesophageal Variceal Hemorrhage. N. Engl. J. Med. 2001, 345, 669–681. [Google Scholar] [CrossRef] [PubMed]
- D’Amico, G.; Garcia-Tsao, G.; Pagliaro, L. Natural history and prognostic indicators of survival in cirrhosis: A systematic review of 118 studies. J. Hepatol. 2006, 44, 217–231. [Google Scholar] [CrossRef] [PubMed]
- Bambha, K.; Kim, W.R.; Pedersen, R.; Bida, J.P.; Kremers, W.K.; Kamath, P.S. Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut 2008, 57, 814–820. [Google Scholar] [CrossRef] [PubMed]
- Bjerring, P.N.; Gluud, L.L. Severe hepatic encephalopathy is an independent predictor of mortality in hospitalised patients with cirrhosis. AME Med. J. 2017, 2, 134. [Google Scholar] [CrossRef]
- Zipprich, A.; Garcia-Tsao, G.; Rogowski, S.; Fleig, W.E.; Seufferlein, T.; Dollinger, M.M. Prognostic indicators of survival in patients with compensated and decompen-sated cirrhosis. Liver Int. 2012, 32, 1407–1414. [Google Scholar] [CrossRef] [Green Version]
- Solà, R.; Alvarez, M.A.; Ballesté, B.; Montoliu, S.; Rivera, M.; Miquel, M.; Cirera, I.; Morillas, R.M.; Coll, S.; Planas, R. Probability of liver cancer and survival in HCV-related or alcoholic-decompensated cirrhosis. A study of 377 patients. Liver Int. 2006, 26, 62–72. [Google Scholar] [CrossRef]
Variable | Non-Alcoholic Liver Cirrhosis | Control | ||
---|---|---|---|---|
n = 109,128 | n = 109,128 | |||
n | % | n | % | |
Sex | ||||
Female | 34,636 | 31.7 | 34,636 | 31.7 |
Male | 74,492 | 68.3 | 74,492 | 68.3 |
Age (years) | ||||
<40 | 8520 | 7.80 | 8520 | 7.80 |
40–49 | 20,078 | 18.4 | 20,078 | 18.4 |
50–59 | 24,915 | 22.8 | 24,915 | 22.8 |
60–69 | 27,444 | 25.2 | 27,444 | 25.2 |
≥70 | 28,171 | 25.8 | 28,171 | 25.8 |
Mean ± SD | 59.4 ± 12.6 | 59.4 ± 12.7 | ||
Etiology | ||||
HBV only | 14,838 | 13.6 | 14,838 | 13.6 |
HCV only | 11,861 | 10.9 | 11,861 | 10.9 |
HBV+HCV | 1425 | 1.31 | 1425 | 1.31 |
NAFLD | 4148 | 3.80 | 4148 | 3.80 |
Comorbidities | ||||
Smoking status (COPD) | 9677 | 8.87 | 9677 | 8.87 |
CCI score | ||||
1 | 61,208 | 56.1 | 61,208 | 56.1 |
≥2 | 47,920 | 43.9 | 47,920 | 43.9 |
Decompensation | ||||
Variceal hemorrhage | 50,451 | 46.2 | 12,234 | 11.2 |
Ascites | 41,792 | 38.3 | 1359 | 1.3 |
Encephalopathy | 34,460 | 31.6 | 989 | 0.9 |
SBP | 16,176 | 14.8 | 2673 | 2.5 |
HCC | 15,777 | 14.5 | 615 | 0.6 |
Jaundice | 5876 | 5.4 | 1135 | 1.0 |
HRS | 3478 | 3.2 | 154 | 0.1 |
Cause of Death | Non-Alcoholic Liver Cirrhosis n = 109,128 | Control n = 109,128 | p Value | ||
---|---|---|---|---|---|
(355,486 Person-Years) | (583,423 Person-Years) | ||||
Deaths (n,%) | Rate (95% CI) | Deaths (n,%) | Rate (95% CI) | ||
All-cause | 46,297 (42.4) | 21.2 (21.0–21.4) | 13,684 (12.5) | 6.27 (6.17–6.37) | <0.0001 |
Variceal hemorrhage | 25,874 (23.7) | 11.9 (11.7–12.0) | 3278 (3.0) | 1.50 (1.45–1.55) | <0.0001 |
Ascites | 22,778 (20.9) | 10.4 (10.3–10.6) | 373 (0.3) | 0.17 (0.15–0.19) | <0.0001 |
Encephalopathy | 20,107 (18.4) | 9.21 (9.09–9.33) | 288 (0.3) | 0.13 (0.12–0.15) | <0.0001 |
SBP | 9564 (8.8) | 4.38 (4.30–4.47) | 650 (0.6) | 0.30 (0.27–0.32) | <0.0001 |
HCC | 8996 (8.2) | 4.12 (4.04–4.21) | 270 (0.2) | 0.12 (0.11–0.14) | <0.0001 |
Jaundice | 2916 (2.7) | 1.34 (1.29–1.38) | 151 (0.1) | 0.07 (0.06–0.08) | <0.0001 |
HRS | 2441 (2.2) | 1.12 (1.07–1.16) | 54 (0.05) | 0.02 (0.02–0.03) | <0.0001 |
Cause of Death | A. HBV Only | B. HCV Only | C. HBV + HCV | D. NAFLD | ||||
---|---|---|---|---|---|---|---|---|
n = 14,838 | n = 11,861 | n = 1425 | n = 4148 | |||||
(41,305.20 Person-Years) | (36,388.40 Person-Years) | (4035.95 Person-Years) | (15,281.62 Person-Years) | |||||
Deaths (n,%) | Rate (95% CI) | Deaths (n,%) | Rate (95% CI) | Deaths (n,%) | Rate (95% CI) | Deaths (n,%) | Rate (95% CI) | |
All-cause | 6480 (43.7) | 21.8 (21.4–22.3) | 4882 (41.2) | 20.6 (20.1–21.1) | 596 (41.8) | 20.9 (19.4–22.4) | 1488 (35.9) | 17.9 (17.1–18.8) |
Variceal hemorrhage | 3324 (22.4) | 11.2 (10.8–11.6) | 2590 (21.8) | 10.9 (10.5–11.3) | 299 (21.0) | 10.5 (9.37–11.6) | 823 (19.8) | 9.92 (9.28–10.6) |
Ascites | 3049 (20.5) | 10.3 (9.93–10.6) | 2235 (18.8) | 9.42 (9.05–9.79) | 254 (17.8) | 8.91 (7.87–9.96) | 710 (17.1) | 8.56 (7.96–9.16) |
Encephalopathy | 2630 (17.7) | 8.86 (8.54–9.19) | 2176 (18.3) | 9.17 (8.81–9.54) | 251 (17.6) | 8.81 (7.77–9.85) | 633 (15.3) | 7.63 (7.06–8.20) |
SBP | 1336 (9.0) | 4.50 (4.27–4.74) | 1019 (8.6) | 4.30 (4.04–4.55) | 126 (8.8) | 4.42 (3.67–5.18) | 310 (7.5) | 3.74 (3.33–4.14) |
HCC | 1988 (13.4) | 6.70 (6.41–6.98) | 1487 (12.5) | 6.27 (5.96–6.58) | 177 (12.4) | 6.21 (5.32–7.10) | 215 (5.2) | 2.59 (2.25–2.93) |
Jaundice | 446 (3.0) | 1.50 (1.36–1.64) | 230 (1.9) | 0.97 (0.84–1.09) | 36 (2.5) | 1.26 (0.85–1.67) | 125 (3.0) | 1.51 (1.24–1.77) |
HRS | 394 (2.7) | 1.33 (1.20–1.46) | 243 (2.0) | 1.02 (0.90–1.15) | 21 (1.5) | 0.74 (0.42–1.05) | 81 (2.0) | 0.98 (0.76–1.19) |
Variable | Event | |||
---|---|---|---|---|
Non-Alcoholic Liver Cirrhosis vs. Control | ||||
n | Adjusted HR * | 95% CI | p-Value | |
(1) All-cause | ||||
Etiology | ||||
HBV only | 7629 | 8.38 | (7.87–8.93) | <0.0001 |
HCV only | 6378 | 4.34 | (4.09–4.60) | <0.0001 |
HBV + HCV | 726 | 6.69 | (5.53–8.10) | <0.0001 |
NAFLD | 1997 | 3.80 | (3.43–4.20) | <0.0001 |
Sex | ||||
Female | 18,081 | 4.70 | (4.54–4.86) | <0.0001 |
Male | 41,900 | 5.34 | (5.22–5.47) | <0.0001 |
Age, years | ||||
<40 | 3252 | 13.3 | (11.9–15.0) | <0.0001 |
40–49 | 9133 | 9.66 | (9.10–10.3) | <0.0001 |
50–59 | 12,562 | 7.33 | (7.00–7.68) | <0.0001 |
60–69 | 15,918 | 4.72 | (4.55–4.89) | <0.0001 |
≥70 | 19,116 | 3.24 | (3.14–3.34) | <0.0001 |
(2) Variceal hemorrhage | ||||
Etiology | ||||
HBV only | 3642 | 16.1 | (14.3–18.0) | <0.0001 |
HCV only | 2980 | 9.00 | (8.09–10.0) | <0.0001 |
HBV + HCV | 335 | 13.0 | (9.15–18.3) | <0.0001 |
NAFLD | 947 | 8.72 | (7.22–10.5) | <0.0001 |
Sex | ||||
Female | 8315 | 11.7 | (10.9–12.5) | <0.0001 |
Male | 20,837 | 12.6 | (12.1–13.2) | <0.0001 |
Age, years | ||||
<40 | 1986 | 34.7 | (27.9–43.2) | <0.0001 |
40–49 | 5460 | 28.9 | (25.7–32.6) | <0.0001 |
50–59 | 6670 | 19.4 | (17.7–21.3) | <0.0001 |
60–69 | 7436 | 11.4 | (10.6–12.2) | <0.0001 |
≥70 | 7600 | 6.17 | (5.83–6.53) | <0.0001 |
(3) Ascites | ||||
Etiology | ||||
HBV only | 3112 | 72.0 | (56.1–92.4) | <0.0001 |
HCV only | 2310 | 39.9 | (31.7–50.3) | <0.0001 |
HBV + HCV | 259 | 74.5 | (30.7–180.6) | <0.0001 |
NAFLD | 721 | 83.3 | (45.9–151.0) | <0.0001 |
Sex | ||||
Female | 7094 | 111.9 | (91.1–137.5) | <0.0001 |
Male | 16,057 | 87.0 | (77.3–97.8) | <0.0001 |
Age, years | ||||
<40 | 1643 | 94.5 | (64.2–139.3) | <0.0001 |
40–49 | 4371 | 108.3 | (84.2–139.1) | <0.0001 |
50–59 | 5535 | 112.6 | (89.6–141.4) | <0.0001 |
60–69 | 5968 | 84.8 | (70.1–102.6) | <0.0001 |
≥70 | 5634 | 79.5 | (65.4–96.7) | <0.0001 |
(4) Encephalopathy | ||||
Etiology | ||||
HBV only | 2698 | 58.0 | (45.6–73.8) | <0.0001 |
HCV only | 2231 | 53.0 | (40.5–69.2) | <0.0001 |
HBV + HCV | 256 | 75.0 | (30.9–181.9) | <0.0001 |
NAFLD | 643 | 83.0 | (44.5–155.1) | <0.0001 |
Sex | ||||
Female | 6604 | 164.5 | (127.3–212.6) | <0.0001 |
Male | 13,791 | 92.0 | (80.7–104.8) | <0.0001 |
Age, years | ||||
<40 | 1493 | 112.5 | (72.4–175.0) | <0.0001 |
40–49 | 4001 | 91.2 | (71.7–116.1) | <0.0001 |
50–59 | 4853 | 125.7 | (97.3–162.6) | <0.0001 |
60–69 | 5253 | 114.7 | (90.8–145.0) | <0.0001 |
≥70 | 4795 | 99.0 | (78.3–125.2) | <0.0001 |
(5) Spontaneous bacterial peritonitis | ||||
Etiology | ||||
HBV only | 1440 | 19.9 | (16.3–24.3) | <0.0001 |
HCV only | 1113 | 14.8 | (12.0–18.3) | <0.0001 |
HBV + HCV | 132 | 32.4 | (14.2–73.5) | <0.0001 |
NAFLD | 336 | 15.9 | (10.6–23.7) | <0.0001 |
Sex | ||||
Female | 3161 | 22.6 | (19.6–26.1) | <0.0001 |
Male | 7053 | 23.4 | (21.2–25.7) | <0.0001 |
Age, years | ||||
<40 | 797 | 55.4 | (36.3–84.7) | <0.0001 |
40–49 | 2117 | 38.3 | (30.9–47.7) | <0.0001 |
50–59 | 2555 | 27.6 | (23.2–32.7) | <0.0001 |
60–69 | 2612 | 23.1 | (19.7–27.0) | <0.0001 |
≥70 | 2133 | 12.3 | (10.7–14.1) | <0.0001 |
(6) Hepatocellular carcinoma | ||||
Etiology | ||||
HBV only | 2047 | 49.8 | (38.4–64.6) | <0.0001 |
HCV only | 1574 | 23.7 | (19.1–29.5) | <0.0001 |
HBV + HCV | 182 | 54.3 | (22.3–132.4) | <0.0001 |
NAFLD | 222 | 40.1 | (18.9–85.2) | <0.0001 |
Sex | ||||
Female | 2618 | 75.1 | (57.0–98.8) | <0.0001 |
Male | 6648 | 46.2 | (40.4–52.9) | <0.0001 |
Age, years | ||||
<40 | 435 | 57.5 | (31.6–104.7) | <0.0001 |
40–49 | 1404 | 66.5 | (46.8–94.5) | <0.0001 |
50–59 | 2358 | 67.3 | (51.4–88.2) | <0.0001 |
60–69 | 2721 | 50.3 | (40.5–62.4) | <0.0001 |
≥70 | 2348 | 38.3 | (30.9–47.4) | <0.0001 |
(7) Jaundice | ||||
Etiology | ||||
HBV only | 480 | 19.9 | (14.0–28.2) | <0.0001 |
HCV only | 253 | 13.8 | (8.97–21.2) | <0.0001 |
HBV + HCV | 31 | 50.4 | (6.90–367.7) | 0.0001 |
NAFLD | 130 | 32.9 | (13.5–80.5) | <0.0001 |
Sex | ||||
Female | 741 | 29.4 | (21.0–41.3) | <0.0001 |
Male | 2326 | 30.0 | (24.9–36.2) | <0.0001 |
Age, years | ||||
<40 | 390 | 59.3 | (31.6–111.1) | <0.0001 |
40–49 | 807 | 62.0 | (39.8–96.7) | <0.0001 |
50–59 | 780 | 33.2 | (23.7–46.7) | <0.0001 |
60–69 | 562 | 24.0 | (17.0–33.8) | <0.0001 |
≥70 | 528 | 13.9 | (10.4–18.6) | <0.0001 |
(8) Hepatorenal syndrome | ||||
Etiology | ||||
HBV only | 407 | 42.7 | (24.6–74.2) | <0.0001 |
HCV only | 251 | 41.2 | (20.4–83.3) | <0.0001 |
HBV + HCV | 22 | 30.2 | (4.05–225.3) | 0.0009 |
NAFLD | 84 | 34.3 | (10.8–108.7) | <0.0001 |
Sex | ||||
Female | 683 | 109.1 | (56.5–210.7) | <0.0001 |
Male | 1812 | 59.3 | (44.1–79.7) | <0.0001 |
Age, years | ||||
<40 | 193 | 69.6 | (25.8–187.4) | <0.0001 |
40–49 | 533 | 155.5 | (64.4–375.1) | <0.0001 |
50–59 | 663 | 90.4 | (49.9–164.1) | <0.0001 |
60–69 | 560 | 70.4 | (39.7–124.8) | <0.0001 |
≥70 | 546 | 34.8 | (22.7–53.4) | <0.0001 |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Hsieh, M.-S.; Cheng, K.-C.; Hsieh, M.-L.; Chiang, J.-H.; Hsieh, V.C.-R. Mortality Risk and Decompensation in Hospitalized Patients with Non-Alcoholic Liver Cirrhosis: Implications for Disease Management. Int. J. Environ. Res. Public Health 2021, 18, 606. https://doi.org/10.3390/ijerph18020606
Hsieh M-S, Cheng K-C, Hsieh M-L, Chiang J-H, Hsieh VC-R. Mortality Risk and Decompensation in Hospitalized Patients with Non-Alcoholic Liver Cirrhosis: Implications for Disease Management. International Journal of Environmental Research and Public Health. 2021; 18(2):606. https://doi.org/10.3390/ijerph18020606
Chicago/Turabian StyleHsieh, Ming-Shun, Kung-Chuan Cheng, Meng-Lun Hsieh, Jen-Huai Chiang, and Vivian Chia-Rong Hsieh. 2021. "Mortality Risk and Decompensation in Hospitalized Patients with Non-Alcoholic Liver Cirrhosis: Implications for Disease Management" International Journal of Environmental Research and Public Health 18, no. 2: 606. https://doi.org/10.3390/ijerph18020606