A clinical staging system for cirrhosis: a multicenter cohort study of 1858 patients

A staging system for cirrhosis has been recently proposed based on varices, ascites and bleeding (J Hepatol 2006;44: 217–31). We aimed at validating the concept of clinical stages for cirrhosis and assessing the role of hepatocellular carcinoma (hcc), encephalopathy (pse) and jaundice. A total of 1858 patients from prospective cohorts were included in the study at the seven participating centers. Survival analysis was performed by the Kaplan-Meier method by individual patient data. Predictive accuracy for 1-year mortality of Pugh score and MELD across stages was assessed by c-statistics. Etiology was from HBV 6%, HCV 35%, alcohol 41%, alcohol and HCV 11%, other 7%; mean age±sd was 56±23, male sex 62%. At diagnosis 667 patients had compensated (330 without and 337 with esophageal varices) and 1146 decompensated cirrhosis,608 with ascites, 248 portal hypertensive bleeding,and 290 ascites and bleeding. In a mean±sd follow-up of 73±79 months 996 patients died and 116 were transplanted.1- and 5-year survival was respectively 99% and 86% for compensated patients without and 96.5% and 72% with varices,85% and 78% for those with bleeding alone,74% and 46% with ascites and 70% and 33% with ascites and bleeding. While 1-year survival after hcc, pse and jaundice was respectively 55%,53% and 58%, they were the first decompensating event respectively in only 4.5%, 4.5% and 3%.Based on survival, five major clinical stages with significantly different outcomes were identified: 1 compensated, no varices, 2 compensated with varices, 3 bleeding, no ascites, 4 ascites (and/or hcc, pse, jaundice), 5 bleeding and ascites (±hcc, pse, jaundice). 1-year transition rate between stages and mortality from each stage is summarized in the figure. c-statistics for 1-year mortality for Pugh and MELD were respectively: 0.76 and 0.68 (p<0.00001). Corresponding values across stages were: 0.85 and 0.77, stage1; 0.66 and 0.48, stage2; 0.71 and 0.64 stage 3; 0.67 and 0.71, stage4; 0.73 and 0.69, stage 5.

Fig.1

Conclusions: five stages of cirrhosis with significantly different outcome have been identified. Predictive accuracy of Child-Pugh score and MELD was unsatisfactory and varied across stages. Accurate prognostic factors per each stage should be investigated.