Clinical Stages and Ordinal Outcomes in Portal Hypertension

Abstract

The concept of clinical stages of cirrhosis has been introduced to identify distinct clinical conditions in the course of the disease with a different outcome severity. The term “clinical” has been used to underscore that they do not necessarily correspond to a pathophysiological progression, and therefore do not occur in a predictable sequence. The two major stages are compensated and decompensated cirrhosis based on the presence or history of any variceal bleeding, ascites, hepatic encephalopathy, and jaundice (although the role of jaundice in this definition is currently under debate). Six substages have been proposed: (1) the absence of esophageal varices without clinically significant portal hypertension (CSPH) defined by the hepatic venous pressure gradient (HVPG) <10 mmHg, (2) no varices with CSPH, and (3) varices in compensated cirrhosis; (4) variceal bleeding without other decompensating events, (5) any single nonbleeding decompensating event; (6) ≥2 of any decompensating events. The six proposed stages are characterized by a progressive increase of the 5-year risk of mortality, from 1.5% in stages 1–2 to 88% in stage 6. This gradual increase of the risk across stages fits well with the concept of ordinal outcomes which are outcome indicators rank-ordered according to severity. The relationship between the clinical stages of cirrhosis and ordinal outcomes and the applicability of ordinal outcomes in portal hypertension and cirrhosis is illustrated in this chapter.