Influence of Recent Advances in Medical Management on Clinical Outcomes of Cirrhosis
2005; Elsevier BV; Volume: 80; Issue: 11 Linguagem: Inglês
10.4065/80.11.1501
ISSN1942-5546
AutoresJayant A. Talwalkar, Patrick S. Kamath,
Tópico(s)Hepatocellular Carcinoma Treatment and Prognosis
ResumoCirrhosis and its disease-related complications are the 12th leading cause of mortality among US adults and are the 5th leading cause of death for individuals aged 45 to 54 years. Hospitalization costs for disease-related complications are estimated at $18,000 per episode of care, and 10% of admitted patients die. Despite these ominous findings, the survival rate of patients with cirrhosis has improved during the past 2 decades. This observation coincides with the conducting and reporting of high-quality randomized controlled trials and observational studies. Therefore, the improved prognosis in cirrhosis may be related to the effective translation of research findings to clinical practice for this patient population. Although explicit data to support this claim are not available, this article reviews the reported trends in clinical outcomes for patients with cirrhosis and the existence of evidence-based medical information that is available to care for these chronically ill patients. Cirrhosis and its disease-related complications are the 12th leading cause of mortality among US adults and are the 5th leading cause of death for individuals aged 45 to 54 years. Hospitalization costs for disease-related complications are estimated at $18,000 per episode of care, and 10% of admitted patients die. Despite these ominous findings, the survival rate of patients with cirrhosis has improved during the past 2 decades. This observation coincides with the conducting and reporting of high-quality randomized controlled trials and observational studies. Therefore, the improved prognosis in cirrhosis may be related to the effective translation of research findings to clinical practice for this patient population. Although explicit data to support this claim are not available, this article reviews the reported trends in clinical outcomes for patients with cirrhosis and the existence of evidence-based medical information that is available to care for these chronically ill patients. Cirrhosis and its disease-related complications are the 12th leading cause of mortality among US adults and are responsible for nearly as many fatalities as diabetes mellitus.1Anderson RN Deaths: leading causes for 2000.Natl Vital Stat Rep. 2002; 50: 1-85PubMed Google Scholar For individuals aged 45 to 54 years, cirrhosis is the fifth leading cause of death. Hospitalization costs for disease-related complications are estimated at $18,000 per episode of care, and 10% of admitted patients die.2Agency for Healthcare Research and Quality HCUPnet: Healthcare cost and utilization project (HCUP).Available at: www.ahrq.gov/data/hcupGoogle Scholar Despite the widespread success of liver transplantation, a growing proportion of individuals who are developing end-stage liver disease will not receive this treatment because of advancing age, comorbid illness, and organ availability. However, over the past 2 decades, the median survival rate of patients with compensated and decompensated cirrhosis has increased. Current methods of diagnosis and treatment, resulting from high-quality randomized controlled trials (RCTs) and observational investigations, may be in part responsible for this trend. We discuss the clinical epidemiology of cirrhosis and portal hypertension and review time trends in survival and the influence that advances in medical management may have on clinical outcomes. Observational cohort studies of compensated cirrhosis that were reported in the English language included the following: diseased populations evaluated at tertiary referral centers, study periods between the years 1958 and 1990, predominant hepatic disease etiologies including alcohol and chronic viral hepatitis, and patient follow-up rates greater than 80%.3Infante-Rivard C Villeneuve JP Esnaola S A framework for evaluating and conducting prognostic studies: an application to cirrhosis of the liver.J Clin Epidemiol. 1989; 42: 791-805Abstract Full Text PDF PubMed Scopus (20) Google Scholar From reported investigations of large cohorts,4Okazaki I Maruyama K Funatsu K Kashiwazaki K Tsuchiya M Ten year survival rate of 131 patients with liver cirrhosis excluded the association of liver carcinoma at the establishment of diagnosis.Gastroenterol Jpn. 1980; 15: 350-354PubMed Google Scholar, 5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar, 6Hashizume M Inokuchi K Beppu K et al.The natural history of non-alcoholic cirrhosis.Gastroenterol Jpn. 1984; 19: 430-435PubMed Google Scholar, 7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar, 8Tanaka R Itoshima T Nagashima H Follow-up study of 582 liver cirrhosis patients for 26 years in Japan.Liver. 1987; 7: 316-324PubMed Google Scholar, 9Gines P Quintero E Arroyo V et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (875) Google Scholar, 10Merkel C Bolognesi M Angeli P et al.Prognostic indicators of survival in patients with cirrhosis and esophageal varices, without previous bleeding.Am J Gastroenterol. 1989; 84: 717-722PubMed Google Scholar, 11Zoli M Cordiani MR Marchesini G et al.Prognostic indicators in compensated cirrhosis.Am J Gastroenterol. 1991; 86: 1508-1513PubMed Google Scholar, 12Sugimura T Tsuji Y Sakamoto M et al.Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s.J Gastroenterol Hepatol. 1994; 9: 154-161Crossref PubMed Scopus (20) Google Scholar, 13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar, 14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar, 15Fattovich G Giustina G Degos F et al.Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients.Gastroenterology. 1997; 112: 463-472Abstract Full Text Full Text PDF PubMed Scopus (1254) Google Scholar, 16Serfaty L Aumaitre H Chazouilleres O et al.Determinants of outcome of compensated hepatitis C virus-related cirrhosis.Hepatology. 1998; 27: 1435-1440Crossref PubMed Scopus (394) Google Scholar, 17Hu KQ Tong MJ The long-term outcomes of patients with compensated hepatitis C virus-related cirrhosis and history of parenteral exposure in the United States.Hepatology. 1999; 29: 1311-1316Crossref PubMed Scopus (249) Google Scholar the median survival of patients with compensated cirrhosis is estimated at between 7 and 10 years from the time of diagnosis. Nearly 100% of individuals affected by compensated cirrhosis from chronic viral hepatitis can expect to survive at least 2 to 5 years after diagnosis7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar, 9Gines P Quintero E Arroyo V et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (875) Google Scholar, 13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar, 14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar, 15Fattovich G Giustina G Degos F et al.Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients.Gastroenterology. 1997; 112: 463-472Abstract Full Text Full Text PDF PubMed Scopus (1254) Google Scholar, 16Serfaty L Aumaitre H Chazouilleres O et al.Determinants of outcome of compensated hepatitis C virus-related cirrhosis.Hepatology. 1998; 27: 1435-1440Crossref PubMed Scopus (394) Google Scholar, 17Hu KQ Tong MJ The long-term outcomes of patients with compensated hepatitis C virus-related cirrhosis and history of parenteral exposure in the United States.Hepatology. 1999; 29: 1311-1316Crossref PubMed Scopus (249) Google Scholar (Figure 1). In the absence of clinical decompensation, the development of splenomegaly,7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar thrombocytopenia,7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar and/or quiescent esophageal varices7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar10Merkel C Bolognesi M Angeli P et al.Prognostic indicators of survival in patients with cirrhosis and esophageal varices, without previous bleeding.Am J Gastroenterol. 1989; 84: 717-722PubMed Google Scholar11Zoli M Cordiani MR Marchesini G et al.Prognostic indicators in compensated cirrhosis.Am J Gastroenterol. 1991; 86: 1508-1513PubMed Google Scholar13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar is associated with a reduced median survival of 4 to 7 years. A population-based study from a similar time period demonstrated equivalent outcomes.5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar The long-term risks of selected disease-related complications of compensated cirrhosis also have been reported (Figure 2). Estimates of 4% to 12% for the annual development of esophageal varices have been reported.14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar18Gores GJ Wiesner RH Dickson ER Zinsmeister AR Jorgensen RA Langworthy A Prospective evaluation of esophageal varices in primary biliary cirrhosis: development, natural history, and influence on survival.Gastroenterology. 1989; 96: 1552-1559Abstract PubMed Google Scholar19D'Amico G Luca A Natural history: clinical-haemodynamic correlations: prediction of the risk of bleeding.Baillieres Clin Gastroenterol. 1997; 11: 243-256Abstract Full Text PDF PubMed Scopus (201) Google Scholar Among patients identified with esophageal varices, the risk of hemorrhage was estimated at 25% to 40% within 2 years of diagnosis.20Christensen E Fauerholdt L Schlichting P Juhl E Poulsen H Tygstrup N Aspects of the natural history of gastrointestinal bleeding in cirrhosis and the effect of prednisone.Gastroenterology. 1981; 81: 944-952Abstract Full Text PDF PubMed Scopus (190) Google Scholar Subsequently, the annual risk of bleeding was reduced to 1% to 3%.21D'Amico G Pagliaro L Bosch J The treatment of portal hypertension: a meta-analytic review.Hepatology. 1995; 22: 332-354Crossref PubMed Google Scholar Ascites5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar, 7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar, 9Gines P Quintero E Arroyo V et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (875) Google Scholar, 14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar, 15Fattovich G Giustina G Degos F et al.Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients.Gastroenterology. 1997; 112: 463-472Abstract Full Text Full Text PDF PubMed Scopus (1254) Google Scholar, 16Serfaty L Aumaitre H Chazouilleres O et al.Determinants of outcome of compensated hepatitis C virus-related cirrhosis.Hepatology. 1998; 27: 1435-1440Crossref PubMed Scopus (394) Google Scholar and hepatic encephalopathy5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar occurred at rates of 5% and 6% per year, respectively. Among patients with compensated and de-compensated cirrhosis, the annual risk of developing hepatocellular carcinoma (HCC) was between 1% and 6%.4Okazaki I Maruyama K Funatsu K Kashiwazaki K Tsuchiya M Ten year survival rate of 131 patients with liver cirrhosis excluded the association of liver carcinoma at the establishment of diagnosis.Gastroenterol Jpn. 1980; 15: 350-354PubMed Google Scholar, 5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar, 6Hashizume M Inokuchi K Beppu K et al.The natural history of non-alcoholic cirrhosis.Gastroenterol Jpn. 1984; 19: 430-435PubMed Google Scholar, 7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar, 8Tanaka R Itoshima T Nagashima H Follow-up study of 582 liver cirrhosis patients for 26 years in Japan.Liver. 1987; 7: 316-324PubMed Google Scholar, 9Gines P Quintero E Arroyo V et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (875) Google Scholar, 10Merkel C Bolognesi M Angeli P et al.Prognostic indicators of survival in patients with cirrhosis and esophageal varices, without previous bleeding.Am J Gastroenterol. 1989; 84: 717-722PubMed Google Scholar, 11Zoli M Cordiani MR Marchesini G et al.Prognostic indicators in compensated cirrhosis.Am J Gastroenterol. 1991; 86: 1508-1513PubMed Google Scholar, 12Sugimura T Tsuji Y Sakamoto M et al.Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s.J Gastroenterol Hepatol. 1994; 9: 154-161Crossref PubMed Scopus (20) Google Scholar, 13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar, 14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar, 15Fattovich G Giustina G Degos F et al.Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients.Gastroenterology. 1997; 112: 463-472Abstract Full Text Full Text PDF PubMed Scopus (1254) Google Scholar, 16Serfaty L Aumaitre H Chazouilleres O et al.Determinants of outcome of compensated hepatitis C virus-related cirrhosis.Hepatology. 1998; 27: 1435-1440Crossref PubMed Scopus (394) Google Scholar, 17Hu KQ Tong MJ The long-term outcomes of patients with compensated hepatitis C virus-related cirrhosis and history of parenteral exposure in the United States.Hepatology. 1999; 29: 1311-1316Crossref PubMed Scopus (249) Google Scholar, 22Fattovich G Giustina G Schalm SW EUROHEP Study Group on Hepatitis B Virus and Cirrhosis et al.Occurrence of hepatocellular carcinoma and decompensation in western European patients with cirrhosis type B.Hepatology. 1995; 21: 77-82PubMed Google Scholar, 23del Olmo JA Serra MA Rodriguez F Escudero A Gilabert S Rodrigo JM Incidence and risk factors for hepatocellular carcinoma in 967 patients with cirrhosis.J Cancer Res Clin Oncol. 1998; 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31: 468-475Crossref PubMed Scopus (501) Google Scholar12Sugimura T Tsuji Y Sakamoto M et al.Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s.J Gastroenterol Hepatol. 1994; 9: 154-161Crossref PubMed Scopus (20) Google Scholar26Magliocchetti N Torchio P Corrao G Arico S Favilli S Prognostic factors for long-term survival in cirrhotic patients after the first episode of liver decompensation.Ital J Gastroenterol Hepatol. 1997; 29: 38-46PubMed Google Scholar, 27Christensen E Krintel JJ Hansen SM Johansen JK Juhl E Prognosis after the first episode of gastrointestinal bleeding or coma in cirrhosis: survival and prognostic factors.Scand J Gastroenterol. 1989; 24: 999-1006Crossref PubMed Scopus (80) Google Scholar, 28Fernandez-Esparrach G Sanchez-Fueyo A Gines P et al.A prognostic model for predicting survival in cirrhosis with ascites.J Hepatol. 2001; 34: 46-52Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar, 29Llach J Gines P Arroyo V et al.Prognostic value of arterial pressure, endogenous vasoactive systems, and renal function in cirrhotic patients admitted to the hospital for the treatment of ascites.Gastroenterology. 1988; 94: 482-487Abstract PubMed Google Scholar, 30Salerno F Borroni G Moser P et al.Survival and prognostic factors of cirrhotic patients with ascites: a study of 134 outpatients.Am J Gastroenterol. 1993; 88: 514-519PubMed Google Scholar, 31Bustamante J Rimola A Ventura PJ et al.Prognostic significance of hepatic encephalopathy in patients with cirrhosis.J Hepatol. 1999; 30: 890-895Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar, 32Hartmann IJ Groeneweg M Quero JC et al.The prognostic significance of subclinical hepatic encephalopathy.Am J Gastroenterol. 2000; 95: 2029-2034Crossref PubMed Google Scholar, 33Das A Dhiman RK Saraswat VA Verma M Naik SR Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis.J Gastroenterol Hepatol. 2001; 16: 531-535Crossref PubMed Scopus (241) Google Scholar During the past 4 decades, the transition rate from compensated to decompensated cirrhosis has remained unchanged, between 5% and 10% annually.7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar, 9Gines P Quintero E Arroyo V et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (875) Google Scholar, 13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar, 14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar, 15Fattovich G Giustina G Degos F et al.Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients.Gastroenterology. 1997; 112: 463-472Abstract Full Text Full Text PDF PubMed Scopus (1254) Google Scholar, 16Serfaty L Aumaitre H Chazouilleres O et al.Determinants of outcome of compensated hepatitis C virus-related cirrhosis.Hepatology. 1998; 27: 1435-1440Crossref PubMed Scopus (394) Google Scholar In turn, 2-year survival rates after onset of complications related to portal hypertension have remained below 50%4Okazaki I Maruyama K Funatsu K Kashiwazaki K Tsuchiya M Ten year survival rate of 131 patients with liver cirrhosis excluded the association of liver carcinoma at the establishment of diagnosis.Gastroenterol Jpn. 1980; 15: 350-354PubMed Google Scholar5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar12Sugimura T Tsuji Y Sakamoto M et al.Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s.J Gastroenterol Hepatol. 1994; 9: 154-161Crossref PubMed Scopus (20) Google Scholar26Magliocchetti N Torchio P Corrao G Arico S Favilli S Prognostic factors for long-term survival in cirrhotic patients after the first episode of liver decompensation.Ital J Gastroenterol Hepatol. 1997; 29: 38-46PubMed Google Scholar, 27Christensen E Krintel JJ Hansen SM Johansen JK Juhl E Prognosis after the first episode of gastrointestinal bleeding or coma in cirrhosis: survival and prognostic factors.Scand J Gastroenterol. 1989; 24: 999-1006Crossref PubMed Scopus (80) Google Scholar, 28Fernandez-Esparrach G Sanchez-Fueyo A Gines P et al.A prognostic model for predicting survival in cirrhosis with ascites.J Hepatol. 2001; 34: 46-52Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar, 29Llach J Gines P Arroyo V et al.Prognostic value of arterial pressure, endogenous vasoactive systems, and renal function in cirrhotic patients admitted to the hospital for the treatment of ascites.Gastroenterology. 1988; 94: 482-487Abstract PubMed Google Scholar, 30Salerno F Borroni G Moser P et al.Survival and prognostic factors of cirrhotic patients with ascites: a study of 134 outpatients.Am J Gastroenterol. 1993; 88: 514-519PubMed Google Scholar, 31Bustamante J Rimola A Ventura PJ et al.Prognostic significance of hepatic encephalopathy in patients with cirrhosis.J Hepatol. 1999; 30: 890-895Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar, 32Hartmann IJ Groeneweg M Quero JC et al.The prognostic significance of subclinical hepatic encephalopathy.Am J Gastroenterol. 2000; 95: 2029-2034Crossref PubMed Google Scholar, 33Das A Dhiman RK Saraswat VA Verma M Naik SR Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis.J Gastroenterol Hepatol. 2001; 16: 531-535Crossref PubMed Scopus (241) Google Scholar (Figure 1). The major causes of death from decompensated cirrhosis without liver transplantation are progressive liver failure, HCC, gastrointestinal bleeding, sepsis, and renal failure.4Okazaki I Maruyama K Funatsu K Kashiwazaki K Tsuchiya M Ten year survival rate of 131 patients with liver cirrhosis excluded the association of liver carcinoma at the establishment of diagnosis.Gastroenterol Jpn. 1980; 15: 350-354PubMed Google Scholar, 5Saunders JB Walters JR Davies AP Paton A A 20-year prospective study of cirrhosis.Br Med J (Clin Res Ed). 1981; 282: 263-266Crossref PubMed Scopus (285) Google Scholar, 6Hashizume M Inokuchi K Beppu K et al.The natural history of non-alcoholic cirrhosis.Gastroenterol Jpn. 1984; 19: 430-435PubMed Google Scholar, 7D'Amico G Morabito A Pagliaro L Marubini E Survival and prognostic indicators in compensated and decompensated cirrhosis.Dig Dis Sci. 1986; 31: 468-475Crossref PubMed Scopus (501) Google Scholar, 8Tanaka R Itoshima T Nagashima H Follow-up study of 582 liver cirrhosis patients for 26 years in Japan.Liver. 1987; 7: 316-324PubMed Google Scholar, 9Gines P Quintero E Arroyo V et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (875) Google Scholar, 10Merkel C Bolognesi M Angeli P et al.Prognostic indicators of survival in patients with cirrhosis and esophageal varices, without previous bleeding.Am J Gastroenterol. 1989; 84: 717-722PubMed Google Scholar, 11Zoli M Cordiani MR Marchesini G et al.Prognostic indicators in compensated cirrhosis.Am J Gastroenterol. 1991; 86: 1508-1513PubMed Google Scholar, 12Sugimura T Tsuji Y Sakamoto M et al.Long-term prognosis and prognostic factors of liver cirrhosis in the 1980s.J Gastroenterol Hepatol. 1994; 9: 154-161Crossref PubMed Scopus (20) Google Scholar, 13Realdi G Fattovich G Hadziyannis S Investigators of the European Concerted Action on Viral Hepatitis (EUROHEP) et al.Survival and prognostic factors in 366 patients with compensated cirrhosis type B: a multicenter study.J Hepatol. 1994; 21: 656-666Abstract Full Text PDF PubMed Scopus (262) Google Scholar, 14Gentilini P Laffi G La Villa G et al.Long course and prognostic factors of virus-induced cirrhosis of the liver.Am J Gastroenterol. 1997; 92: 66-72PubMed Google Scholar, 15Fattovich G Giustina G Degos F et al.Morbidity and mortality in compensated cirrhosis type C: a retrospective follow-up study of 384 patients.Gastroenterology. 1997; 112: 463-472Abstract Full Text Full Text PDF PubMed Scopus (1254) Google Scholar, 16Serfaty L Aumaitre H Chazouilleres O et al.Determinants of outcome of compensated hepatitis C virus-related cirrhosis.Hepatology. 1998; 27: 1435-1440Crossref PubMed Scopus (394) Google Scholar, 17Hu KQ Tong MJ The long-term outcomes of patients with compensated hepatitis C virus-related cirrhosis and history of parenteral exposure in the United States.Hepatology. 1999; 29: 1311-1316Crossref PubMed Scopus (249) Google Scholar, 26Magliocchetti N Torchio P Corrao G Arico S Favilli S Prognostic factors for long-term survival in cirrhotic patients after the first episode of liver decompensation.Ital J Gastroenterol Hepatol. 1997; 29: 38-46PubMed Google Scholar, 27Christensen E Krintel JJ Hansen SM Johansen JK Juhl E Prognosis after the first episode of gastrointestinal bleeding or coma in cirrhosis: survival and prognostic factors.Scand J Gastroenterol. 1989; 24: 999-1006Crossref PubMed Scopus (80) Google Scholar, 28Fernandez-Esparrach G Sanchez-Fueyo A Gines P et al.A prognostic model for predicting survival in cirrhosis with ascites.J Hepatol. 2001; 34: 46-52Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar, 29Llach J Gines P Arroyo V et al.Prognostic value of arterial pressure, endogenous vasoactive systems, and renal function in cirrhotic patients admitted to the hospital for the treatment of ascites.Gastroenterology. 1988; 94: 482-487Abstract PubMed Google Scholar, 30Salerno F Borroni G Moser P et al.Survival and prognostic factors of cirrhotic patients with ascites: a study of 134 outpatients.Am J Gastroenterol. 1993; 88: 514-519PubMed Google Scholar, 31Bustamante J Rimola A Ventura PJ et al.Prognostic significance of hepatic encephalopathy in patients with cirrhosis.J Hepatol. 1999; 30: 890-895Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar, 32Hartmann IJ Groeneweg M Quero JC et al.The prognostic significance of subclinical hepatic encephalopathy.Am J Gastroenterol. 2000; 95: 2029-2034Crossref PubMed Google Scholar, 33Das A Dhiman RK Saraswat VA Verma M Naik SR Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis.J Gastroenterol Hepatol. 2001; 16: 531-535Crossref Pu
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