Natural history of compensated viral cirrhosis: a prospective study on the incidence and hierarchy of major complications

Abstract

Background and aims: The natural history of initially compensated cirrhosis due to hepatitis B (HBV) or hepatitis C (HCV) virus is only partially defined. We have investigated morbidity and mortality rates and the hierarchy of complications in compensated viral cirrhosis over a long follow up period.

Patients and methods: A cohort of Italian patients with initially compensated cirrhosis of viral aetiology were followed up at six monthly intervals with laboratory tests to identify major complications (ascites, gastrointestinal bleeding, portal-systemic encephalopathy, hepatocellular carcinoma) and to assess the progression of Child's stage and mortality rate due to liver related causes.

Results: Between 1986 and 1996, 312 patients (43 HBV positive, 254 HCV positive, and 15 HBV and HCV coinfected) were included. During a median follow up of 93 (range 14-194) months, 102 (32.6%) patients developed at least one complication (HCV positive 31.1%; HBV positive 34.8%; HBV and HCV coinfected 53.3%). Overall, the most frequent complication was hepatocellular carcinoma which occurred in 65 (20.8%) cases, followed by ascites (61 cases, 19.5%), gastrointestinal bleeding (14 cases, 4.5%), and portal-systemic encephalopathy (six cases, 1.9%). Progression of Child's stage was observed in 62 patients (19.8%). Death from liver disease occurred in 58 (18.6%) cases and in 70.7% this was due to hepatocellular carcinoma. Hepatocellular carcinoma was the first complication to develop in 59 cases and represented the most frequent first complication in both HCV and HBV/ HCV related cirrhosis.

Conclusions: These results indicate significant morbidity and mortality during the first decade after diagnosis of compensated cirrhosis due to HBV and/or HCV, and identify hepatocellular carcinoma as the most frequent and life threatening complication, particularly in HCV positive cases.

Figure 1

Cumulative probability of hepatocellular carcinoma (HCC), ascites, variceal bleeding, and portal-systemic encephalopathy during follow up in 312 patients with initially compensated cirrhosis of viral aetiology (Kaplan-Meier method).

Figure 2

Incidence of hepatocellular carcinoma (HCC) and liver related mortality rate during follow up in the whole population (Kaplan-Meier method).

Figure 3

Cumulative incidence of ascites appearance in relation to development of hepatocellular carcinoma (HCC) during follow up (Kaplan-Meier method and log rank test).

Figure 4

Cumulative probability of hepatocellular carcinoma (HCC) (A), ascites (B), variceal bleeding (C), and portal-systemic encephalopathy (D) during follow up in the different aetiological subgroups (Kaplan-Meier method). HCV, hepatitis C virus; HBsAg, hepatitis B surface antigen.