title: Mortality risk according to different clinical characteristics of first episode of liver decompensation in cirrhotic patients: a nationwide, prospective, 3-year follow-up study in Italy.
abstract: OBJECTIVE
  The occurrence of decompensation marks a crucial turning point in the course of cirrhosis. The purpose of this study was to assess the risk of mortality according to the clinical characteristics of first decompensation, considering also the impact of acute-on-chronic liver failure (AoCLF).
  
  
  METHODS
  We conducted a prospective nationwide inception cohort study in Italy. Decompensation was defined by the presence of ascites, either overt or detected by ultrasonography (UD), gastroesophageal variceal bleeding (GEVB), and hepatic encephalopathy (HE). AoCLF was defined according to the Asian Pacific Association for the Study of the Liver criteria. Multivariable Cox proportional hazards regression was used to analyze the risk of failure (death or orthotopic liver transplantation (OLT)).
  
  
  RESULTS
  A total of 490 consecutive cirrhotic patients (314 males, mean age 60.9±12.6 years) fulfilled the study criteria. AoCLF was identified in 59 patients (12.0%). Among the remaining 431 patients, ascites were found in 330 patients (76.6%): in 257 (77.8%) as overt ascites and in 73 (22.2%) as UD ascites. GEVB was observed in 77 patients (17.9%) and HE in 30 patients (7.0%). After a median follow-up of 33 months, 24 patients underwent OLT and 125 died. The cumulative incidence of failure (death or OLT) after 1, 2, and 3 years was, respectively, 28, 53, and 62% in patients with AoCLF; 10, 18, and 25% in patients with UD ascites; 17, 31, and 41% in patients with overt ascites; and 8, 12, and 24% in patients with GEVB (P<0.0001).
  
  
  CONCLUSIONS
  AoCLF is responsible for a relevant proportion of first decompensation in cirrhotic patients and is associated with the poorest outcome. Patients with UD ascites do not have a negligible mortality rate and require clinical monitoring similar to that of patients with overt ascites.
authors.affiliation: Dipartimento di Medicina Interna, A.O. Fatebenefratelli e Oftalmico, Milano, Italy.
authors.forename: Savino
authors.initials: S
authors.lastname: Bruno
authors.forename: Simone
authors.initials: S
authors.lastname: Saibeni
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Bagnardi
authors.forename: Carmen
authors.initials: C
authors.lastname: Vandelli
authors.forename: Massimo
authors.initials: M
authors.lastname: De Luca
authors.forename: Martina
authors.initials: M
authors.lastname: Felder
authors.forename: Anna Ludovica
authors.initials: AL
authors.lastname: Fracanzani
authors.forename: Cleofe
authors.initials: C
authors.lastname: Prisco
authors.forename: Giovanna
authors.initials: G
authors.lastname: Vitaliani
authors.forename: Loredana
authors.initials: L
authors.lastname: Simone
authors.forename: Giovanni Battista
authors.initials: GB
authors.lastname: Gaeta
authors.forename: Maria
authors.initials: M
authors.lastname: Stanzione
authors.forename: Marcello
authors.initials: M
authors.lastname: Persico
authors.forename: Caterina
authors.initials: C
authors.lastname: Furlan
authors.forename: Tommaso
authors.initials: T
authors.lastname: Stroffolini
authors.forename: Francesco
authors.initials: F
authors.lastname: Salerno
authors.forename: Patrick
authors.initials: P
authors.lastname: Maisonneuve
authors.forename: Piero Luigi
authors.initials: PL
authors.lastname: Almasio
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001201:Ascites / Q000209:etiology; D006528:Carcinoma, Hepatocellular / Q000209:etiology; D004932:Esophageal and Gastric Varices / Q000188:drug therapy / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy / Q000209:etiology; D006501:Hepatic Encephalopathy / Q000209:etiology; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008103:Liver Cirrhosis / Q000150:complications / Q000401:mortality* / Q000601:surgery; D017093:Liver Failure / Q000209:etiology / Q000401:mortality* / Q000601:surgery; D008113:Liver Neoplasms / Q000209:etiology; D016031:Liver Transplantation / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012720:Severity of Illness Index; D055815:Young Adult