Predicting mortality risk in patients with compensated HCV-induced cirrhosis: a long-term prospective study.
OBJECTIVE
The identification of prognostic factors associated with mortality is crucial in any clinical setting.


METHODS
We enrolled in a prospective study 352 patients with compensated hepatitis C virus (HCV)-induced cirrhosis, consecutively observed between 1989 and 1992. At entry, patients underwent upper endoscopy to detect esophageal varices, and were then surveilled by serial clinical and ultrasonographic examination. The model for end-stage liver disease (MELD) score was calculated with information collected at enrollment. Baseline predictors and intercurrent events associated with mortality were assessed using the Cox regression model.


RESULTS
During a median follow-up of 14.4 years, 194 subjects received a single course of interferon monotherapy, 131 patients developed decompensation (ascites, bleeding, hepatic encephalopathy), 109 patients had hepatocellular carcinoma (HCC), 9 had liver transplant, and 158 died. Esophageal varices were associated with development of decompensation (hazard ratio (HR), 2.09; 95% confidence interval (CI), 1.33-3.30) and liver-related death (HR, 2.27; 95% CI, 1.41-3.66). A MELD score of > 10 predicted overall mortality (HR, 2.15; 95% CI, 1.50-3.09). Overall survival of patients with MELD < or = 10 was 80% at 10 years. HCC occurrence increased the risk of decompensation fivefold (HR, 5.52; 95% CI, 3.77-8.09). Hepatic and overall mortality hazard ratios were 8.62 (95% CI, 5.57-13.3) and 3.80 (95% CI, 2.67-5.42), respectively, for patients who developed HCC, and 16.9 (95% CI, 9.97-28.6) and 7.08 (95% CI, 4.88-10.2) for those who experienced decompensation.


CONCLUSIONS
In patients with compensated HCV-induced cirrhosis, the presence of esophageal varices at baseline predicted decompensation and mortality. The development of HCC during follow-up strongly hastens the occurrence of decompensation, which is the main determinant of death. Patients with a MELD score < or = 10 at study entry had a prolonged life expectancy.
Department of Internal Medicine, AO Fatebenefratelli e Oftalmico, Milan, Italy. savino.bruno@fbf.milano.it
Savino
S
Bruno
Massimo
M
Zuin
Andrea
A
Crosignani
Sonia
S
Rossi
Felice
F
Zadra
Luigi
L
Roffi
Mauro
M
Borzio
Alessandro
A
Redaelli
Alberto
A
Chiesa
Enrico Maria
EM
Silini
Piero Luigi
PL
Almasio
Patrick
P
Maisonneuve
D000328:Adult; D000368:Aged; D000998:Antiviral Agents / Q000627:therapeutic use; D044963:Biopsy, Fine-Needle; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D018450:Disease Progression; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000401:mortality* / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D019698:Hepatitis C, Chronic / Q000150:complications* / Q000188:drug therapy / Q000473:pathology; D006801:Humans; D007150:Immunohistochemistry; D016898:Interferon-alpha / Q000627:therapeutic use; D053208:Kaplan-Meier Estimate; D008103:Liver Cirrhosis / Q000209:etiology / Q000401:mortality / Q000473:pathology* / Q000821:virology*; D017093:Liver Failure / Q000401:mortality* / Q000503:physiopathology / Q000821:virology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011336:Probability; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors
D000998:Antiviral Agents; D016898:Interferon-alpha