Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients

作者：D'Amico, G.^*; Pasta, L.; Morabito, A.; D'Amico, M.; Caltagirone, M.; Malizia, G.; Tine, F.; Giannuoli, G.; Traina, M.; Vizzini, G.; Politi, F.; Luca, A.; Virdone, R.; Licata, A.; Pagliaro, L.

来源：Alimentary Pharmacology and Therapeutics, 2014, 39(10): 1180-1193.

DOI：10.1111/apt.12721

• LAENNEC STAGING SYSTEM
• NATURAL-HISTORY
• LIVER-CIRRHOSIS
• HEPATITIS-C
• DECOMPENSATED CIRRHOSIS
• COMPENSATED CIRRHOSIS
• PORTAL-HYPERTENSION
• ESOPHAGEAL-VARICES
• SCORING SYSTEM
• MORTALITY RISK

Background @@@ Morphological, haemodynamic and clinical stages of cirrhosis have been proposed, although no definite staging system is yet accepted for clinical practice. @@@ Aim @@@ To investigate whether clinical complications of cirrhosis may define different prognostic disease stages. @@@ Methods @@@ 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. @@@ Results @@@ Major patient characteristics were: 199 females, 295 males, 404 HCV+, 377 compensated, 117 decompensated cirrhosis. The mean follow-up was 145 +/- 109months 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. @@@ Conclusion @@@ The development of oesophago-gastric varices and decompensating events in cirrhosis identify five prognostic stages with significantly increasing mortality risks.

• 出版日期2014-5