Factors Affecting the in-Hospital Mortality in Patients with Diffuse Large B-Cell Lymphoma: A National Inpatient Sample Study (2018-2020)

Introduction: Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma and is the most common non-Hodgkin's lymphoma arising from mature B cells. It can occur either de novo by BCL6 rearrangement or by the transformation of many different types of low-grade lymphomas, including follicular lymphoma, marginal zone lymphoma, lymphoplasmacytic lymphoma and chronic lymphocytic leukemia (Richter's transformation). Patients often present with a rapidly growing symptomatic mass in nodal or extranodal tissues such as the stomach, gastrointestinal tract or lungs, central nervous system, or other sites and commonly experience B symptoms of fever, weight loss and drenching night sweats. Treatment delay in DLBCL patients can present with sepsis, acute respiratory failure, spontaneous tumor lysis syndrome, acute kidney injury caused by tumor lysis syndrome and gastrointestinal bleeding. Despite recent advancements in treatment, in-hospital mortality remains significant. Understanding factors contributing to morbidity and in-hospital mortality is important to improve clinical practices and patient outcomes. Methods: We analyzed the National Inpatient Sample database from 2018 to 2020 to identify all adult hospitalizations > 18 years with a diagnosis of Diffuse Large B-cell lymphoma (DLBCL) using appropriate ICD 10 codes. These hospitalizations were further stratified into those with and without the outcome of mortality. Various complications were queried using ICD 10 codes. We compared the baseline characteristics, inpatient complications, hospital resource utilization such as length of hospital stay (LOS), and total hospital costs in DLBCL hospitalizations with and without the outcome of mortality. Categorical variables were compared using the chi-square test, and the t-test compared continuous variables. Multivariable regression analyses were performed adjusting for demographics, hospital-level characteristics, and relevant comorbidities. Results: We identified a total of 222,765 adult hospitalizations with a primary diagnosis of DLBCL, of which 10450 (4.69%) died during hospitalization. Among DLBCL hospitalizations who died, 40% (4180) are females and the remaining 60% (6270) are males and a majority of them were found to be whites (69%). Among various inpatient DLBCL complications, acute kidney injury (AKI) is more prevalent (19.7%) compared to other complications like acute respiratory failure (ARF) (8.8%), sepsis (5.7%), tumor lysis syndrome (TLS) (3.1%), gastrointestinal bleeding (GIB) (2.4%). In Univariate analysis, DLBCL hospitalizations who died had higher odds of complications such as TLS (OR 4.85, 95% CI: 4.21-5.60, P < 0.01), Sepsis (OR 9.10, 95% CI: 8.15-10.17, P < 0.01), AKI (OR 7.29, 95% CI: 6.60-8.03, P < 0.01), ARF (OR 20.21, 95% CI: 18.28-22.35, P < 0.01), GIB (OR 3.40, 95% CI: 2.84-4.08, P < 0.01) compared to those without. Multivariate analysis after adjusting for potential confounding factors showed that the odds ratios reduced but remained significant for DLBCL Hospitalizations with the outcome of mortality when compared to those without: For specific events, TLS (OR 4.62, 95% CI: 3.99-5.34, P < 0.01), Sepsis (OR 8.35, 95% CI: 7.44-9.36, P < 0.01), AKI (OR 6.99, 95% CI: 6.27-7.80, P < 0.01), ARF (OR 18.78, 95% CI: 16.86-20.93, P < 0.01), GIB (OR 3.10, 95% CI: 2.57-3.74, P < 0.01). Lastly, DLBCL hospitalizations with the outcome of mortality have a longer length of stay (mean of 13 vs 7 days, p<0.001) and higher total hospital costs (mean $239,627 vs $109,891, p<0.01) compared to those without the outcome of mortality. Conclusion: Despite being an aggressive malignancy, Diffuse Large B-cell lymphoma (DLBCL) is potentially curable with intensive chemo-immunotherapy regimens. Based on our study, acute renal failure, sepsis, and acute respiratory failure, tumor lysis syndrome, gastrointestinal bleeding are independently associated with in-hospital mortality in patients with DLBC. Although acute renal failure is the most common complication, acute respiratory failure presents significantly higher odds of mortality. Timely and effective management of these complications can enhance outcomes for DLBCL patients, potentially reducing mortality rates, shortening hospital stays, and decreasing overall healthcare costs.