Hemoglobin-to-Red Cell Distribution Width Ratio as an Independent Predictor of Short-Term Mortality in Septic Patients with Cirrhosis: A Retrospective Cohort Study

Background Patients with cirrhosis who develop sepsis face high short-term mortality, and current prognostic tools may not capture risk in this combined context. We evaluated whether the hemoglobin-to-red cell distribution width ratio (HRR), a simple index derived from routine blood counts, predicts 30- and 90-day mortality in this population. Methods We conducted a retrospective cohort study using the MIMIC-IV database (2008–2019). Adults at their first intensive care unit admission with sepsis and cirrhosis were included. HRR was calculated from the first 24-hour hemoglobin and red cell distribution width values. Primary outcomes were all-cause mortality at 30 and 90 days. Survival was compared across HRR tertiles using Kaplan–Meier analysis and log-rank tests. Cox proportional hazards models estimated associations for HRR treated continuously and by tertiles, with stepwise adjustment for demographics, vital signs, laboratory indices, comorbidities, illness severity, and intensive care therapies. Restricted cubic splines assessed non-linearity. Results Among 2,634 patients (median age 60 years; 64.4% men), lower HRR was associated with greater illness severity and higher crude mortality. Thirty-day mortality was 39.7%, 28.5%, and 24.8% across the lowest to highest HRR tertiles; 90-day mortality was 51.0%, 38.0%, and 31.2% (both P < 0.001). In fully adjusted models, each 1-unit increase in HRR was associated with lower hazards of death at 30 days (hazard ratio 0.378; 95% CI, 0.248–0.578) and 90 days (0.305; 0.209–0.444). Compared with the lowest tertile, the highest tertile showed reduced risk at 30 days (0.626; 0.523–0.749) and 90 days (0.570; 0.486–0.669); the middle tertile also had lower risk (30 days: 0.812; 0.686–0.962; 90 days: 0.792; 0.684–0.918). Spline analyses suggested a steep risk decline at low HRR values that plateaued around 0.55–0.60. Conclusions Lower admission HRR independently identifies higher 30- and 90-day mortality risk in septic patients with cirrhosis. Because it is inexpensive and readily available, HRR may complement existing assessments to support early risk stratification and management in critical care settings.