Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.

Liver transplantation significantly improves the survival and quality of life of patients with end-stage cirrhosis. However, a large proportion of cirrhotic patients still die while on the transplant list because of an insufficient number of donors and because of the lack of an accurate prediction of life expectancy. Although many prognostic models have been proposed in the last two decades to predict mortality in cirrhosis, the Child–Pugh score [1] is by far the most largely used both in clinical practice and in clinical research. Recently, the model for end stage liver disease (MELD) has replaced the Child–Pugh score in the United States for prioritizing liver donor allocation [2]. MELD is considered more reproducible than the Child– Pugh score because it does not include subjective variables such as ascites and encephalopathy. However, obtaining the score requires computing and it is, therefore, much less practical than the Child–Pugh score for individual estimates at the bedside. Moreover, the MELD score has not been proven to be superior to the Child–Pugh score in terms of predictive accuracy [3], and both may be unsatisfactory when applied separately to compensated and decompensated patients [4]. It is in fact well known that life expectancies in compensated and decompensated cirrhosis are strikingly different and it is, therefore, conceivable that prognostic indicators may be different or may have a different weight according to the disease stage [4]. In this article we outline the natural history of cirrhosis and report on a systematic review of the literature regarding predictors of mortality in cirrhosis in order to