Clinical Rheumatology

, Volume 32, Issue 3, pp 361–367 | Cite as

Indications for hospitalization and in-hospital mortality in Thai systemic sclerosis

  • Sittichai Netwijitpan
  • Chingching FoocharoenEmail author
  • Ajanee Mahakkanukrauh
  • Siraphop Suwannaroj
  • Ratanavadee Nanagara
Original Article


This study aimed to identify the indications for hospitalization, hospital mortality rate, predictors of hospital mortality, and clinical parameters affecting length of stay (LOS) among Thai systemic sclerosis (SSc). A retrospective study was performed in SSc patients admitted in Khon Kaen University, Thailand, between January 2008 and December 2010. The respective clinical factors affecting LOS and predictors of mortality were analyzed using the Spearman's rank correlation and the Cox regression model. There were 202 hospital admissions among 131 SSc patients. The female-to-male ratio was 1.6:1. The median age at admission was 54.7 years (interquartile range (IQR) 49.2–62.9), the duration of disease at admission was 2.9 years (IQR 1.1–7.8), and the LOS was 5 days (IQR 2–10). The indications for hospitalization were divided equally between SSc-related and non-SSc-related events (53.5 vs. 46.5 %, respectively). The most common indication for hospitalization was infection (23.3 %) and pneumonia is the most common cause of infection (58.0 %). Prolonged LOS was related to fatigability status (p < 0.01), intestinal involvement (p < 0.01), electrolyte disorders (p < 0.01), multiple comorbidities (p < 0.01), modified Rodnan skin score ≥20 points (p = 0.01), disease duration under 5 years (p = 0.02), cardiac arrhythmia (p = 0.04), and deficiency anemia (p = 0.04). Hospital mortality was 16.8 per 100 person-years (95 % confidence interval (95 % CI) 10.8–24.3). Infection (59.1 %) was the most common cause of death, particularly from bacterial pneumonia. Clinical predictors of mortality were: disseminated intravascular coagulation related to infection (hazard ratio (HR) 52.73; 95 % CI 1.26–403.74), cardiac arrhythmia (HR 32.89; 95 % CI 3.00–359.95), electrolyte disorders (HR 15.66; 95 % CI 2.04–119.98), renal crisis (HR 13.38; 95 % CI 1.80–99.36), intestinal involvement (HR 10.42; 95 % CI 2.58–42.01), admission due to a non-SSc-related condition (HR 8.93; 95 % CI 2.21–36.13), and disease duration under 5 years (HR 6.67; 95 % CI 1.21–36.52). Infection was the most common cause of hospitalization. Prolonged LOS and hospital mortality should be warning signs in patients with shorter disease duration, presence of intestinal involvement, cardiac arrhythmia, and multiple comorbidities.


Cause of death Hospitalization Length of stay Mortality Scleroderma Systemic sclerosis 



We thank the Faculty of Medicine for its support and Mr. Bryan Roderick Hamman and Mrs. Janice Loewen-Hamman for assistance with the English language presentation of the manuscript.




  1. 1.
    Nikpour M, Stevens WM, Herrick AL, Proudman SM (2010) Epidemiology of systemic sclerosis. Best Pract Res Clin Rheumatol 24(6):857–869PubMedCrossRefGoogle Scholar
  2. 2.
    LeRoy EC, Black C, Fleischmajer R, Jablonska S, Krieg T, Medsger TA et al (1988) Scleroderma (systemic sclerosis): classification, subsets and pathogenesis. J Rheumatol 15(2):202–205PubMedGoogle Scholar
  3. 3.
    Steen VD, Medsger TA Jr (2000) Severe organ involvement in systemic sclerosis with diffuse scleroderma. Arthritis Rheum 43(11):2437–2444PubMedCrossRefGoogle Scholar
  4. 4.
    Tyndall AJ, Bannert B, Vonk M, Airò P, Cozzi F, Carreira PE et al (2010) Causes and risk factors for death in systemic sclerosis: a study from the EULAR scleroderma trials and research (EUSTAR) database. Ann Rheum Dis 69(10):1809–1815PubMedCrossRefGoogle Scholar
  5. 5.
    Nietert PJ, Silver RM (2003) Patterns of hospital admissions and emergency room visits among patients with scleroderma in South Carolina, USA. J Rheumatol 30(6):1238–1243PubMedGoogle Scholar
  6. 6.
    Chung L, Krishnan E, Chakravarty EF (2007) Hospitalizations and mortality in systemic sclerosis: results from the nationwide inpatient sample. Rheumatology (Oxford) 46(12):1808–1813CrossRefGoogle Scholar
  7. 7.
    Ioannidis JPA, Vlachoyiannopoulos PG, Haidich A-B, Medsger TA Jr, Lucas M, Michet CJ et al (2005) Mortality in systemic sclerosis: an international meta-analysis of individual patient data. Am J Med 118(1):2–10PubMedCrossRefGoogle Scholar
  8. 8.
    Ranque B, Mouthon L (2010) Geoepidemiology of systemic sclerosis. Autoimmun Rev 9(5):A311–A318PubMedCrossRefGoogle Scholar
  9. 9.
    No authors listed (1980) Preliminary criteria for the classification of systemic sclerosis (scleroderma). Subcommittee for scleroderma criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee. Arthritis Rheum 23(5):581–590Google Scholar
  10. 10.
    Foocharoen C, Nanagara R, Kiatchoosakun S, Suwannaroj S, Mahakkanukrauh A (2011) Prognostic factors of mortality and 2-year survival analysis of systemic sclerosis with pulmonary arterial hypertension in Thailand. Int J Rheum Dis 14(3):282–289PubMedCrossRefGoogle Scholar
  11. 11.
    Perera A, Fertig N, Lucas M, Rodriguez-Reyna TS, Hu P, Steen VD et al (2007) Clinical subsets, skin thickness progression rate, and serum antibody levels in systemic sclerosis patients with anti-topoisomerase I antibody. Arthritis Rheum 56(8):2740–2746PubMedCrossRefGoogle Scholar
  12. 12.
    Levi M, Ten Cate H (1999) Disseminated intravascular coagulation. N Engl J Med 341(8):586–592PubMedCrossRefGoogle Scholar
  13. 13.
    Domsic RT, Rodriguez-Reyna T, Lucas M, Fertig N, Medsger TA Jr (2011) Skin thickness progression rate: a predictor of mortality and early internal organ involvement in diffuse scleroderma. Ann Rheum Dis 70(1):104–109PubMedCrossRefGoogle Scholar
  14. 14.
    Khanna D, Denton CP (2010) Evidence-based management of rapidly progressing systemic sclerosis. Best Pract Res Clin Rheumatol 24(3):387–400PubMedCrossRefGoogle Scholar
  15. 15.
    Baron M, Hudson M, Steele R (2009) Malnutrition is common in systemic sclerosis: results from the Canadian scleroderma research group database. J Rheumatol 36(12):2737–2743PubMedCrossRefGoogle Scholar
  16. 16.
    Lim SL, Ong KCB, Chan YH, Loke WC, Ferguson M, Daniels L (2012) Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 31(3):345–350PubMedCrossRefGoogle Scholar
  17. 17.
    Valentini G, Della Rossa A, Bombardieri S, Bencivelli W, Silman AJ, D’Angelo S et al (2001) European multicentre study to define disease activity criteria for systemic sclerosis. II. Identification of disease activity variables and development of preliminary activity indexes. Ann Rheum Dis 60(6):592–598PubMedCrossRefGoogle Scholar

Copyright information

© Clinical Rheumatology 2012

Authors and Affiliations

  • Sittichai Netwijitpan
    • 1
  • Chingching Foocharoen
    • 1
    Email author
  • Ajanee Mahakkanukrauh
    • 1
  • Siraphop Suwannaroj
    • 1
  • Ratanavadee Nanagara
    • 1
  1. 1.Division of Allergy–Immunology–Rheumatology, Department of Medicine, Faculty of MedicineKhon Kaen UniversityKhon KaenThailand

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