This article was accepted for publication after full peer-review.
Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients
Article first published online: 23 MAR 2014
© 2014 John Wiley & Sons Ltd
Alimentary Pharmacology & Therapeutics
Volume 39, Issue 10, pages 1180–1193, May 2014
How to Cite
D'Amico, G., Pasta, L., Morabito, A., D'Amico, M., Caltagirone, M., Malizia, G., Tinè, F., Giannuoli, G., Traina, M., Vizzini, G., Politi, F., Luca, A., Virdone, R., Licata, A. and Pagliaro, L. (2014), Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients. Alimentary Pharmacology & Therapeutics, 39: 1180–1193. doi: 10.1111/apt.12721
This article is dedicated to Andy Burroughs for his continuous and valuable contribution to research in hepatology.
- Issue published online: 16 APR 2014
- Article first published online: 23 MAR 2014
- Manuscript Accepted: 3 MAR 2014
- Manuscript Revised: 2 MAR 2014
- Manuscript Revised: 18 FEB 2014
- Manuscript Received: 30 JAN 2014
Morphological, haemodynamic and clinical stages of cirrhosis have been proposed, although no definite staging system is yet accepted for clinical practice.
To investigate whether clinical complications of cirrhosis may define different prognostic disease stages.
Analysis of the database from a prospective inception cohort of 494 patients. Decompensation was defined by ascites, bleeding, jaundice or encephalopathy. Explored potential prognostic stages: 1, compensated cirrhosis without oesophago-gastric varices; 2, compensated cirrhosis with varices; 3, bleeding without other complications; 4, first nonbleeding decompensation; 5, any second decompensating event. Patient flow across stages was assessed by a competing risks analysis.
Major patient characteristics were: 199 females, 295 males, 404 HCV+, 377 compensated, 117 decompensated cirrhosis. The mean follow-up was 145 ± 109 months without dropouts. Major events: 380 deaths, 326 oesophago-gastric varices, 283 ascites, 158 bleeding, 146 encephalopathy, 113 jaundice, 126 hepatocellular carcinoma and 19 liver transplantation. Patients entering each prognostic stage along the disease course were: 202, stage 1; 216, stage 2; 75 stage 3; 206 stage 4; 213 stage 5. Five-year transition rate towards a different stage, for stages 1–4 was 34.5%, 42%, 65% and 78%, respectively (P < 0.0001); 5-year mortality for stages 1–5 was 1.5%, 10%, 20%, 30% and 88% respectively (P < 0.0001). An exploratory analysis showed that this patient stratification may configure a prognostic system independent of the Child–Pugh score, Model for End Stage Liver Disease and comorbidity.
The development of oesophago-gastric varices and decompensating events in cirrhosis identify five prognostic stages with significantly increasing mortality risks.