Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage

Analysis of a US Multicenter Prospective Study

Brett E. Fortune, Guadalupe Garcia-Tsao*, Maria Ciarleglio, Yanhong Deng, Michael B. Fallon, Samuel Sigal, Naga P. Chalasani, Joseph K. Lim, Adrian Reuben, Hugo E. Vargas, Gary Abrams, Michele D. Lewis, Tarek Hassanein, James F. Trotter, Arun J. Sanyal, Kimberly L. Beavers, Daniel Ganger, Paul J. Thuluvath, Norman D. Grace, Roberto J. Groszmann & 1 others for the Vapreotide Study Group

*Corresponding author for this work

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

Goals/Background: Data on acute variceal hemorrhage (AVH) in the United States is limited and the best method to stratify risk is not clear. Taking advantage of a prospective US cohort study, we aimed to (1) describe clinical outcomes of AVH and their predictors; (2) compare predictors of 6-week mortality. Study: Prospective 15-center US cohort of patients with cirrhosis presenting with endoscopically proven AVH, all of whom received antibiotics, vapreotide (a somatostain analog) infusion and endoscopic band ligation. Patients were enrolled between August 2006 and April 2008. Primary outcome was 6-week mortality. Secondary outcome was 5-day treatment failure. The prognostic value of Child-Turcotte-Pugh (CTP) class, Model for End-stage Liver Disease (MELD) score and a recent recalibrated MELD were compared. Results: Seventy eligible patient were enrolled; 18 (26%) patients died within 6-weeks of index bleed. Demographic, clinical, and laboratory data were compared between survivors and nonsurvivors. Multivariate models showed that admission CTP or the MELD score (separately) were independent predictors of survival. The discriminative values of CTP (area under receiver operating characteristic: 0.75) and MELD (area under receiver operating characteristic: 0.79) were good and not significantly different (P=0.27). However, calibration (correlation between observed and predicted mortality) test was significantly better for CTP than for MELD, with the recently described recalibrated MELD model having the worst agreement. Predicted mortality for CTP-A was <10%, CTP-B 10% to 30%; and CTP-C >33%. Conclusions: AVH mortality of 26% in the United States is in the upper range limit compared with recent series but may be due to inclusion of patients with more advanced cirrhosis. CTP score has the best overall performance in the prediction of 6-week mortality and is best at stratifying risk.

Original languageEnglish (US)
Pages (from-to)446-453
Number of pages8
JournalJournal of Clinical Gastroenterology
Volume51
Issue number5
DOIs
StatePublished - Jan 1 2017

Fingerprint

End Stage Liver Disease
Multicenter Studies
Prospective Studies
Hemorrhage
Mortality
ROC Curve
Fibrosis
Child Mortality
Treatment Failure
Calibration
Ligation
Survivors
Cohort Studies
Demography
Anti-Bacterial Agents
Survival

Keywords

  • GI bleeding
  • cirrhosis
  • mortality
  • risk stratification

ASJC Scopus subject areas

  • Gastroenterology

Cite this

Fortune, B. E., Garcia-Tsao, G., Ciarleglio, M., Deng, Y., Fallon, M. B., Sigal, S., ... for the Vapreotide Study Group (2017). Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage: Analysis of a US Multicenter Prospective Study. Journal of Clinical Gastroenterology, 51(5), 446-453. https://doi.org/10.1097/MCG.0000000000000733
Fortune, Brett E. ; Garcia-Tsao, Guadalupe ; Ciarleglio, Maria ; Deng, Yanhong ; Fallon, Michael B. ; Sigal, Samuel ; Chalasani, Naga P. ; Lim, Joseph K. ; Reuben, Adrian ; Vargas, Hugo E. ; Abrams, Gary ; Lewis, Michele D. ; Hassanein, Tarek ; Trotter, James F. ; Sanyal, Arun J. ; Beavers, Kimberly L. ; Ganger, Daniel ; Thuluvath, Paul J. ; Grace, Norman D. ; Groszmann, Roberto J. ; for the Vapreotide Study Group. / Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage : Analysis of a US Multicenter Prospective Study. In: Journal of Clinical Gastroenterology. 2017 ; Vol. 51, No. 5. pp. 446-453.
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abstract = "Goals/Background: Data on acute variceal hemorrhage (AVH) in the United States is limited and the best method to stratify risk is not clear. Taking advantage of a prospective US cohort study, we aimed to (1) describe clinical outcomes of AVH and their predictors; (2) compare predictors of 6-week mortality. Study: Prospective 15-center US cohort of patients with cirrhosis presenting with endoscopically proven AVH, all of whom received antibiotics, vapreotide (a somatostain analog) infusion and endoscopic band ligation. Patients were enrolled between August 2006 and April 2008. Primary outcome was 6-week mortality. Secondary outcome was 5-day treatment failure. The prognostic value of Child-Turcotte-Pugh (CTP) class, Model for End-stage Liver Disease (MELD) score and a recent recalibrated MELD were compared. Results: Seventy eligible patient were enrolled; 18 (26{\%}) patients died within 6-weeks of index bleed. Demographic, clinical, and laboratory data were compared between survivors and nonsurvivors. Multivariate models showed that admission CTP or the MELD score (separately) were independent predictors of survival. The discriminative values of CTP (area under receiver operating characteristic: 0.75) and MELD (area under receiver operating characteristic: 0.79) were good and not significantly different (P=0.27). However, calibration (correlation between observed and predicted mortality) test was significantly better for CTP than for MELD, with the recently described recalibrated MELD model having the worst agreement. Predicted mortality for CTP-A was <10{\%}, CTP-B 10{\%} to 30{\%}; and CTP-C >33{\%}. Conclusions: AVH mortality of 26{\%} in the United States is in the upper range limit compared with recent series but may be due to inclusion of patients with more advanced cirrhosis. CTP score has the best overall performance in the prediction of 6-week mortality and is best at stratifying risk.",
keywords = "GI bleeding, cirrhosis, mortality, risk stratification",
author = "Fortune, {Brett E.} and Guadalupe Garcia-Tsao and Maria Ciarleglio and Yanhong Deng and Fallon, {Michael B.} and Samuel Sigal and Chalasani, {Naga P.} and Lim, {Joseph K.} and Adrian Reuben and Vargas, {Hugo E.} and Gary Abrams and Lewis, {Michele D.} and Tarek Hassanein and Trotter, {James F.} and Sanyal, {Arun J.} and Beavers, {Kimberly L.} and Daniel Ganger and Thuluvath, {Paul J.} and Grace, {Norman D.} and Groszmann, {Roberto J.} and {for the Vapreotide Study Group}",
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Fortune, BE, Garcia-Tsao, G, Ciarleglio, M, Deng, Y, Fallon, MB, Sigal, S, Chalasani, NP, Lim, JK, Reuben, A, Vargas, HE, Abrams, G, Lewis, MD, Hassanein, T, Trotter, JF, Sanyal, AJ, Beavers, KL, Ganger, D, Thuluvath, PJ, Grace, ND, Groszmann, RJ & for the Vapreotide Study Group 2017, 'Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage: Analysis of a US Multicenter Prospective Study', Journal of Clinical Gastroenterology, vol. 51, no. 5, pp. 446-453. https://doi.org/10.1097/MCG.0000000000000733

Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage : Analysis of a US Multicenter Prospective Study. / Fortune, Brett E.; Garcia-Tsao, Guadalupe; Ciarleglio, Maria; Deng, Yanhong; Fallon, Michael B.; Sigal, Samuel; Chalasani, Naga P.; Lim, Joseph K.; Reuben, Adrian; Vargas, Hugo E.; Abrams, Gary; Lewis, Michele D.; Hassanein, Tarek; Trotter, James F.; Sanyal, Arun J.; Beavers, Kimberly L.; Ganger, Daniel; Thuluvath, Paul J.; Grace, Norman D.; Groszmann, Roberto J.; for the Vapreotide Study Group.

In: Journal of Clinical Gastroenterology, Vol. 51, No. 5, 01.01.2017, p. 446-453.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage

T2 - Analysis of a US Multicenter Prospective Study

AU - Fortune, Brett E.

AU - Garcia-Tsao, Guadalupe

AU - Ciarleglio, Maria

AU - Deng, Yanhong

AU - Fallon, Michael B.

AU - Sigal, Samuel

AU - Chalasani, Naga P.

AU - Lim, Joseph K.

AU - Reuben, Adrian

AU - Vargas, Hugo E.

AU - Abrams, Gary

AU - Lewis, Michele D.

AU - Hassanein, Tarek

AU - Trotter, James F.

AU - Sanyal, Arun J.

AU - Beavers, Kimberly L.

AU - Ganger, Daniel

AU - Thuluvath, Paul J.

AU - Grace, Norman D.

AU - Groszmann, Roberto J.

AU - for the Vapreotide Study Group

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Goals/Background: Data on acute variceal hemorrhage (AVH) in the United States is limited and the best method to stratify risk is not clear. Taking advantage of a prospective US cohort study, we aimed to (1) describe clinical outcomes of AVH and their predictors; (2) compare predictors of 6-week mortality. Study: Prospective 15-center US cohort of patients with cirrhosis presenting with endoscopically proven AVH, all of whom received antibiotics, vapreotide (a somatostain analog) infusion and endoscopic band ligation. Patients were enrolled between August 2006 and April 2008. Primary outcome was 6-week mortality. Secondary outcome was 5-day treatment failure. The prognostic value of Child-Turcotte-Pugh (CTP) class, Model for End-stage Liver Disease (MELD) score and a recent recalibrated MELD were compared. Results: Seventy eligible patient were enrolled; 18 (26%) patients died within 6-weeks of index bleed. Demographic, clinical, and laboratory data were compared between survivors and nonsurvivors. Multivariate models showed that admission CTP or the MELD score (separately) were independent predictors of survival. The discriminative values of CTP (area under receiver operating characteristic: 0.75) and MELD (area under receiver operating characteristic: 0.79) were good and not significantly different (P=0.27). However, calibration (correlation between observed and predicted mortality) test was significantly better for CTP than for MELD, with the recently described recalibrated MELD model having the worst agreement. Predicted mortality for CTP-A was <10%, CTP-B 10% to 30%; and CTP-C >33%. Conclusions: AVH mortality of 26% in the United States is in the upper range limit compared with recent series but may be due to inclusion of patients with more advanced cirrhosis. CTP score has the best overall performance in the prediction of 6-week mortality and is best at stratifying risk.

AB - Goals/Background: Data on acute variceal hemorrhage (AVH) in the United States is limited and the best method to stratify risk is not clear. Taking advantage of a prospective US cohort study, we aimed to (1) describe clinical outcomes of AVH and their predictors; (2) compare predictors of 6-week mortality. Study: Prospective 15-center US cohort of patients with cirrhosis presenting with endoscopically proven AVH, all of whom received antibiotics, vapreotide (a somatostain analog) infusion and endoscopic band ligation. Patients were enrolled between August 2006 and April 2008. Primary outcome was 6-week mortality. Secondary outcome was 5-day treatment failure. The prognostic value of Child-Turcotte-Pugh (CTP) class, Model for End-stage Liver Disease (MELD) score and a recent recalibrated MELD were compared. Results: Seventy eligible patient were enrolled; 18 (26%) patients died within 6-weeks of index bleed. Demographic, clinical, and laboratory data were compared between survivors and nonsurvivors. Multivariate models showed that admission CTP or the MELD score (separately) were independent predictors of survival. The discriminative values of CTP (area under receiver operating characteristic: 0.75) and MELD (area under receiver operating characteristic: 0.79) were good and not significantly different (P=0.27). However, calibration (correlation between observed and predicted mortality) test was significantly better for CTP than for MELD, with the recently described recalibrated MELD model having the worst agreement. Predicted mortality for CTP-A was <10%, CTP-B 10% to 30%; and CTP-C >33%. Conclusions: AVH mortality of 26% in the United States is in the upper range limit compared with recent series but may be due to inclusion of patients with more advanced cirrhosis. CTP score has the best overall performance in the prediction of 6-week mortality and is best at stratifying risk.

KW - GI bleeding

KW - cirrhosis

KW - mortality

KW - risk stratification

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