title: Competing risks and prognostic stages of cirrhosis: a 25-year inception cohort study of 494 patients.
abstract: BACKGROUND
  Morphological, haemodynamic and clinical stages of cirrhosis have been proposed, although no definite staging system is yet accepted for clinical practice.
  
  
  OBJECTIVE
  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 ± 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.
  
  
  CONCLUSIONS
  The development of oesophago-gastric varices and decompensating events in cirrhosis identify five prognostic stages with significantly increasing mortality risks.
authors.affiliation: Gastroenterology Unit, Ospedale V Cervello, Palermo, Italy.
authors.forename: G
authors.initials: G
authors.lastname: D'Amico
authors.forename: L
authors.initials: L
authors.lastname: Pasta
authors.forename: A
authors.initials: A
authors.lastname: Morabito
authors.forename: M
authors.initials: M
authors.lastname: D'Amico
authors.forename: M
authors.initials: M
authors.lastname: Caltagirone
authors.forename: G
authors.initials: G
authors.lastname: Malizia
authors.forename: F
authors.initials: F
authors.lastname: Tinè
authors.forename: G
authors.initials: G
authors.lastname: Giannuoli
authors.forename: M
authors.initials: M
authors.lastname: Traina
authors.forename: G
authors.initials: G
authors.lastname: Vizzini
authors.forename: F
authors.initials: F
authors.lastname: Politi
authors.forename: A
authors.initials: A
authors.lastname: Luca
authors.forename: R
authors.initials: R
authors.lastname: Virdone
authors.forename: A
authors.initials: A
authors.lastname: Licata
authors.forename: L
authors.initials: L
authors.lastname: Pagliaro
mesh_terms: D000328:Adult; D000368:Aged; D001201:Ascites / Q000453:epidemiology / Q000209:etiology; D006528:Carcinoma, Hepatocellular / Q000453:epidemiology* / Q000209:etiology; D015331:Cohort Studies; D016208:Databases, Factual; D018450:Disease Progression; D004932:Esophageal and Gastric Varices / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007565:Jaundice / Q000453:epidemiology / Q000209:etiology; D008103:Liver Cirrhosis / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology*; D008113:Liver Neoplasms / Q000453:epidemiology* / Q000209:etiology; D016031:Liver Transplantation / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment