Author information

¹Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia. Electronic address: jasmohan.bajaj@vcuhealth.org.

²Department of Medicine, University of California, San Francisco, California.

³Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.

⁴Department of Medicine, Dallas VA Medical Center, Dallas, Texas.

⁵Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

⁶Department of Medicine, West Haven VA Medical Center, West Haven, Connecticut.

⁷Department of Medicine, Mayo Clinic, Phoenix, Arizona.

⁸Department of Medicine, Mayo Clinic, Rochester, Minnesota.

⁹Department of Medicine, University of Washington, Seattle, Washington.

¹⁰Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia.

¹¹Department of Periodontics, Virginia Commonwealth University, Richmond, Virginia.

¹²Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia.

¹³Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Abstract

Background & aims: Hospitalizations are a sentinel event in cirrhosis; however, the changing demographics in patients with cirrhosis require updated hospitalization prediction models. Periodontitis is a risk factor for liver disease and potentially progression. The aim of this study was to determine factors, including poor oral health, associated with 3-month hospitalizations in a multi-center cohort of outpatients with cirrhosis.

Methods: North American Consortium for Study of End-stage Liver Disease (NACSELD-3), a new study cohort, recruits outpatients with cirrhosis. Cirrhosis details, demographics, minimal hepatic encephalopathy (MHE), frailty, and comorbid conditions including oral health were collected. All patients were followed for 3 months for nonelective hospitalizations. Multi-variable models were created for this outcome using demographics, cirrhosis details, oral health, MHE, frailty, and comorbid conditions with K-fold internal validation using 25%/75% split.

Results: A total of 442 outpatients (70% men; 37% compensated; Model for End-stage Liver Disease-Sodium, 12; 42% ascites; and 33% prior HE) were included. MHE was found in 70%, frailty in 10%; and both in 8%. In terms of oral health, 15% were edentulous and 10% had prior periodontitis. Regarding 3-month hospitalizations, 14% were admitted for mostly liver-related reasons. These patients were more likely to be decompensated with higher cirrhosis complications, MHE, frailty and periodontitis history. Multi-variable analysis showed prior periodontitis (P = .026), composite MHE + frailty score (P = .0016), ascites (P = .004), prior HE (P = .008), and hydrothorax (P = .004) were associated with admissions using the training and validation subsets.

Conclusions: In a contemporaneous, prospective, multi-center cohort study in outpatients with cirrhosis, poor oral health is significantly associated with 3-month hospitalizations independent of portal hypertensive complications, MHE, and frailty. Potential strategies to reduce hospitalizations should consider oral evaluation in addition to MHE and frailty assessment in practice pathways.