Background: Despite presence of clinical management protocols for treating severe acute malnutrition, its case fatality rate remains high in health facilities from developing countries. Objectives: To assess treatment outcomes and associated risk factors for death of children aged 6 -59 months with complicated severe acute malnutrition. Methods: A cohort of 469 children aged 6 -59 months with complicated severe acute malnutrition admitted to nutritional rehabilitation units of Mekelle City were followed retrospectively. Data on nutritional status, socio-demographic factors, admission medical conditions and management characteristics were collected. Median test, Chi-square test and Cox's proportional hazard regression were used for statistical analysis. Results: Overall case fatality rate was 12.8%. The median length of stay and median weight gain was 17 days and 12.1 g/kg/day, respectively. Two third of the deaths occurred during the first week of admission. Diarrhea (HR: 2.45, 95% CI: 1.23 -4.89), IV antibiotic (HR: 5.87, 95% CI: 1.73 -19.87), blood transfusion (HR: 3.05, 95% CI: 1.51 -6.17) and IV infusion (HR: 2.52, 95% CI: 1.25 -5.07) were found to be associated with time to death. Conclusion: Unacceptably high case fatality rate was observed at the therapeutic feeding units of Mekelle City. Diarrhea, IV antibiotic, blood transfusion and IV infusion were the risk factors for death of severely malnourished under five children. Appropriate clinical management of severe acute malnutrition in the first week of inpatient stay with frequent monitoring for signs associated with clinical deterioration of children hospitalized with complicated SAM is most critical to the survival of the children.