Prediction of Decompensation in Patients with Compensated Cirrhosis: Does Etiology Matter?

Risk of hepatic decompensation or HCC is similar in patients with ALD- and MASLD-cirrhosis: A population-based cohort study

BACKGROUND

It is unclear if the risk of hepatic decompensation or hepatocellular carcinoma (HCC) differs between patients with compensated alcohol-related liver disease (ALD)- and metabolic dysfunction-associated steatotic liver disease (MASLD)-cirrhosis. We investigated the risk to develop hepatic decompensation or HCC based on ALD or MASLD as the underlying etiology of cirrhosis.

METHODS

All patients with a new diagnosis in hospital-based outpatient care of ALD- or MASLD-cirrhosis in Sweden between 2002 and 2020 were identified using national registers. Hepatic decompensation was analyzed as a composite outcome with HCC. Cox regression was employed to compare rates of hepatic decompensation or HCC, and subsequent death.

RESULTS

1660 patients with ALD-cirrhosis and 943 patients with MASLD-cirrhosis were identified. The median ages were 64 years (IQR 57-70) and 69 years (IQR 62-75) in patients with ALD- and MASLD-cirrhosis, respectively. Patients with ALD-cirrhosis consisted of 69.4 % males, compared to 47.6 % males in the MASLD-cirrhosis group. 581 (35 %) patients with ALD-cirrhosis and 284 (30 %) patients with MASLD-cirrhosis developed hepatic decompensation or HCC (median follow-up time: 25 months), resulting in an adjusted hazard ratio of 1.12 (ALD- vs. MASLD-cirrhosis, 95 %-confidence interval=0.88-1.41). The adjusted risk of mortality afterwards was lower in patients with ALD-cirrhosis compared to patients with MASLD-cirrhosis (adjusted hazard ratio 0.62, 95 %-confidence interval=0.39-0.97).

CONCLUSIONS

The risk of hepatic decompensation or HCC is comparable in patients with ALD- and MASLD-cirrhosis, but the risk of mortality after a decompensation event or HCC tends to be higher in patients with MASLD-cirrhosis.

Acute and non-acute decompensation of liver cirrhosis (47/130)

In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.

Comparison of different severity scores in correlating hemoglobin levels with the severity of hepatic decompensation: An observational study

BACKGROUND

Chronic liver disease is a growing global health problem, leading to hepatic decompensation characterized by an array of clinical and biochemical complications. Several scoring systems have been introduced in assessing the severity of hepatic decompensation with the most frequent ones are Child-Pugh score, model of end-stage liver disease (MELD) score, and MELD-Na score. Anemia is frequently observed in cirrhotic patients and is linked to worsened clinical outcomes. Although studies have explored anemia in liver disease, few have investigated the correlation of hemoglobin level with the severity of hepatic decompensation.

AIM

To determine the relationship between hemoglobin levels and the severity of decompensated liver disease and comparing the strength of this correlation using the Child-Pugh, MELD, and MELD-Na scores.

METHODS

This cross-sectional study was conducted at a tertiary care hospital with 652 decompensated liver disease patients enrolled in the study. Data was collected on demographics, clinical history, and laboratory findings, including hemoglobin levels, bilirubin, albumin, prothrombin time (international normalized ratio), sodium, and creatinine. The Child-Pugh, MELD, and MELD-Na scores were calculated. Statistical analysis was performed using Statistical Package for the Social Sciences version 26, and correlations between hemoglobin levels and severity scores were assessed using Spearman's correlation coefficient.

RESULTS

The study included 405 males (62.1%) and 247 females (37.9%) with an average age of 58.8 years. Significant inverse correlations were found between hemoglobin levels and Child-Pugh, MELD, and MELD-Na scores (P < 0.01), with the MELD scoring system being the strongest correlator among all. One-way analysis of variance revealed significant differences in hemoglobin levels across the severity groups of each scoring system (P = 0.001). Tukey's post hoc analysis confirmed significant internal differences among each severity group.

CONCLUSION

Understanding the correlation between hemoglobin and liver disease severity can improve patient management by offering insights into prognosis and guiding treatment decisions.

Association between Clot Waveform Analysis Parameters and the Severity of Liver Cirrhosis

BACKGROUND

 Clot waveform analysis (CWA) provides a global assessment of hemostasis and may be useful for patients with cirrhosis with complex hemostatic abnormalities. This study aimed to assess the association between prothrombin time (PT-) and activated partial thromboplastin time (aPTT-) based CWA parameters and cirrhosis severity and prospectively evaluate the role of CWA in predicting mortality and acute decompensation (AD) over 1 year.

METHODS

 This prospective study included adult patients with cirrhosis between June 2021 and December 2023 at Chulalongkorn University Hospital. The PT- and aPTT-based CWA parameters were obtained using an automated coagulation analyzer.

RESULTS

 A total of 560 patients with cirrhosis were included; 165 (29.5%) and 47 (11.5%) had Child-Turcotte-Pugh (CTP) B and C cirrhosis, respectively. The PT- and aPTT-based CWA parameters, including maximum velocity (min1), maximum acceleration (min2), and maximum deceleration (max2), were significantly lower (p ≤ 0.05) in patients with decompensated cirrhosis than in those with compensated cirrhosis. Additionally, CWA values were significantly higher in patients with higher CTP and Model for End-Stage Liver Disease (MELD) scores. Multivariable analysis revealed that liver stiffness (LS) and max2 of PT-based CWA assay were independently associated with CTP B/C. In addition, min2 and max2 of PT-based CWA assay were independently associated with 1-year mortality. No significant differences in CWA parameters were observed between patients with and without portal vein thrombosis. CWA parameters were not related to AD during the 1-year follow-up.

CONCLUSION

 A hypocoagulable profile based on CWA parameters is associated with advanced-stage cirrhosis. CWA may be a useful objective marker for assessing cirrhosis severity and predicting 1-year mortality.

Natural history and progression of metabolic dysfunction-associated steatotic liver disease

The natural history of metabolic dysfunction-associated steatotic liver disease (MASLD), previously referred to as non-alcoholic fatty liver disease (NAFLD), is complex and long. A minority of patients develop inflammation and risk progressive fibrosis that can result in cirrhosis. Progression to cirrhosis occurs in 3-5% of patients and often takes more than 20 years. This narrative review presents an update on the natural history of MASLD, discussing studies and risk estimates for progression to severe outcomes, such as decompensated cirrhosis or hepatocellular carcinoma. We highlight the dynamic progression of liver damage, how to identify patients whose disease progresses over time, and how risk factors might be mitigated to reduce the risk for disease progression.

Effect of diabetes on mortality and liver transplantation in alcoholic liver cirrhotic patients with acute decompensation

BACKGROUND

Previous studies have investigated the influence of diabetes on alcoholic liver cirrhosis patients, leaving its impact unclear. Thus, we conducted a study to reveal the association of diabetes and clinical outcomes of such patients.

MATERIALS AND METHODS

We prospectively collected data from multicenter pertaining to 965 patients diagnosed with alcoholic liver cirrhosis, all of whom were admitted due to acute decompensation between 2015 and 2019. Risk of major precipitating factors and incidences of death or liver transplantation in patients with and without diabetes was comparatively assessed. Propensity score (PS) matching was performed at a 1:2 ratio for accurate comparisons.

RESULTS

The mean age was 53.4 years, and 81.0% of the patients were male. Diabetes was prevalent in 23.6% of the cohort and was positively correlated with hepatic encephalopathy and upper gastrointestinal bleeding, although not statistically significant. During a median follow-up of 903.5 person-years (PYs), 64 patients with and 171 without diabetes died or underwent liver transplantation, with annual incidence of 33.6/100 PYs and 24.0/100 PYs, respectively. In the PS-matched cohort, the incidence of death or liver transplantation was 36.8/100 PYs and 18.6/100 PYs in the diabetes and matched control group, respectively. After adjusting for various factors, coexisting diabetes significantly heightened the risk of death or liver transplantation in the short and long term, in addition to prolonged prothrombin time, low serum albumin, elevated total bilirubin and creatinine, and decreased serum sodium levels.

CONCLUSIONS

Diabetes increases the risk of death or liver transplantation in patients with alcoholic liver cirrhosis.

Validation of MELD 3.0 in patients with alcoholic liver cirrhosis using prospective KACLiF cohort

BACKGROUND AND AIM

The Model for End-Stage Liver Disease (MELD) is a reliable prognostic tool for short-term outcome prediction in patients with end-stage liver disease. MELD 3.0 was introduced to enhance the predictive accuracy. This study assessed the performance of MELD 3.0, in comparison to MELD and MELD-Na, in patients with alcoholic liver cirrhosis.

METHODS

This multicenter prospective cohort study comprised patients with alcoholic cirrhosis admitted for acute deterioration of liver function in the Republic of Korea between 2015 and 2019. This study compared the predictive abilities of MELD, MELD-Na, and MELD 3.0, for 30-day and 90-day outcomes, specifically death or liver transplantation, and explored the factors influencing these outcomes.

RESULTS

A total of 1096 patients were included in the study, with a mean age of 53.3 ± 10.4 years, and 82.0% were male. The mean scores for MELD, MELD-Na, and MELD 3.0 at the time of admission were 18.7 ± 7.2, 20.6 ± 7.7, and 21.0 ± 7.8, respectively. At 30 and 90 days, 7.2% and 14.1% of patients experienced mortality or liver transplantation. The areas under the receiver operating characteristic curves for MELD, MELD-Na, and MELD 3.0 at 30 days were 0.823, 0.820, and 0.828; and at 90 days were 0.765, 0.772, and 0.776, respectively. Factors associated with the 90-day outcome included concomitant chronic viral hepatitis, prolonged prothrombin time, elevated levels of aspartate transaminase, bilirubin, and creatinine, and low albumin levels.

CONCLUSION

MELD 3.0 demonstrated improved performance compared to previous models, although the differences were not statistically significant.

Computed Tomographic Findings of Liver Cirrhosis in Dogs: Comparison between Compensated and Decompensated Cirrhosis

This study aimed to describe computed tomography (CT) characteristics of histologically confirmed cirrhosis and to compare these CT characteristics between compensated and decompensated cirrhosis. Sixteen dogs who underwent contrast CT and histopathological examinations were included; eleven dogs were assigned to the compensated group, and five dogs were assigned to the decompensated group. Irregular hepatic contours with a diffuse nodular distribution and hepatic lymph node enlargement are common concomitant features of cirrhotic livers on CT images. The enhancement patterns of the regenerative nodules and hepatic parenchyma were not significantly different from each other. Hypoattenuating areas with delayed contrast enhancement indicating fibrotic tissue were confirmed in 56.3% of cases. Hypoattenuating wedge-shaped area or nodule with minor or no contrast enhancement (histopathologically confirmed as focal necrosis) were confirmed in 37.5% of cases. Among CT variables, only normalized liver volume and portal vein-to-aorta ratio were significantly lower (p = 0.038 and 0.003, respectively) in the decompensated group. In conclusion, this study presented the CT features of cirrhosis and identified CT features that can discriminate between compensated and decompensated cirrhosis. Specifically, lower normalized liver volume and the portal vein-to-aorta ratio might be useful indicators for the progression of cirrhosis to the decompensated phase.

Spleen volume-based non-invasive tool for predicting hepatic decompensation in people with compensated cirrhosis (CHESS1701)

Background & Aims

Non-invasive stratification of the liver decompensation risk remains unmet in people with compensated cirrhosis. This study aimed to develop a non-invasive tool (NIT) to predict hepatic decompensation.

Methods

This retrospective study recruited 689 people with compensated cirrhosis (median age, 54 years; 441 men) from 5 centres from January 2016 to June 2020. Baseline abdominal computed tomography (CT), clinical features, and liver stiffness were collected, and then the first decompensation was registered during the follow-up. The spleen-based model was designed for predicting decompensation based on a deep learning segmentation network to generate the spleen volume and least absolute shrinkage and selection operator (LASSO)-Cox. The spleen-based model was trained on the training cohort of 282 individuals (Institutions I–III) and was validated in 2 external validation cohorts (97 and 310 individuals from Institutions IV and V, respectively) and compared with the conventional serum-based models and the Baveno VII criteria.

Results

The decompensation rate at 3 years was 23%, with a 37.6-month median (IQR 21.1–52.1 months) follow-up. The proposed model showed good performance in predicting decompensation (C-index ≥0.84) and outperformed the serum-based models (C-index comparison test p <0.05) in both the training and validation cohorts. The hazard ratio (HR) for decompensation in individuals with high risk was 7.3 (95% CI 4.2–12.8) in the training and 5.8 (95% CI 3.9–8.6) in the validation (log-rank test, p <0.05) cohorts. The low-risk group had a negligible 3-year decompensation risk (≤1%), and the model had a competitive performance compared with the Baveno VII criteria.

Conclusions

This spleen-based model provides a non-invasive and user-friendly method to help predict decompensation in people with compensated cirrhosis in diverse healthcare settings where liver stiffness is not available.

Lay summary

People with compensated cirrhosis with larger spleen volume would have a higher risk of decompensation. We developed a spleen-based model and validated it in external validation cohorts. The proposed model might help predict hepatic decompensation in people with compensated cirrhosis when invasive tools are unavailable.

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Spleen volume is a predictor for decompensation by rapid risk increasement after spleen volume >364 cm³.

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The spleen-based model revealed incremental prognostic improvement (C-index >0.84).

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Low-risk patients identified by the spleen-based model had a negligible 3-year risk (≤1%) of decompensation.

Frailty is associated with increased risk of cirrhosis disease progression and death

BACKGROUND AND AIMS

The Liver Frailty Index (LFI) is a well-studied tool that evaluates frailty in patients with cirrhosis. Consisting of grip strength, chair stands, and balance testing, the LFI has been associated with increased mortality in patients awaiting liver transplant. We aimed to extend our understanding of frailty in cirrhosis by exploring the relationship between the LFI and the risk of (1) cirrhosis progression, (2) mortality, and (3) unplanned hospitalizations, in both compensated and decompensated disease.

APPROACH AND RESULTS

Adult patients with cirrhosis from four centers in North America and one in India were included. Frailty was measured at baseline using the LFI and categorized as robust (LFI < 3.2), prefrail (LFI 3.2-4.5), and frail (LFI > 4.5). Progression of cirrhosis was defined by an increase in clinical stage, ranging from 1 to 5, from baseline using the D'Amico classification. Factors associated with progression, mortality, and hospitalizations were evaluated using multivariate regression models, with transplant as a competing risk. In total, 822 patients with cirrhosis were included. Average Model for End-Stage Liver Disease (MELD) score was 15.5 ± 6.0. In patients with compensated cirrhosis, being frail versus robust was associated with increased risk of progression to the next cirrhosis stage or to death (HR, 2.45; 95% CI, 1.14-5.29) and with an increased risk of unplanned hospitalizations (2.32; 95% CI, 1.13-4.79), after adjusting for age, sex, and MELD score. Similar HRs were observed in patients with decompensated cirrhosis.

CONCLUSIONS

Frailty was an independent predictor of cirrhosis progression or death and unplanned hospitalization across patients with compensated and decompensated cirrhosis. Future studies are needed to evaluate the possibility of slowing cirrhosis disease progression by reversing or preventing frailty.

Towards a new definition of decompensated cirrhosis

There is a universal agreement that the occurrence of clinical complications, such as ascites, hepatic encephalopathy, gastrointestinal bleeding, and jaundice mark the transition from the compensated to the decompensated stage of cirrhosis. Decompensation is associated with a substantial worsening of patient prognosis and is therefore considered the most important stratification variable for the risk of death. However, this classification is an oversimplification, as it does not discriminate between the prognostic subgroups that characterise the course of decompensation, which depends on the type and number of decompensating events. A deeper insight into the clinical course of decompensated cirrhosis is provided by observational studies characterising acute decompensation (AD), which occurs mostly in patients who have already experienced decompensating events. Decompensation presents as AD in a portion of patients while in many others it presents as a slow development of ascites or mild grade 1 or 2 hepatic encephalopathy, or jaundice, not requiring hospitalisation. Thus, we propose that decompensation of cirrhosis occurs through 2 distinct pathways: a non-acute and an acute (which includes acute-on-chronic liver failure) pathway. Moreover, while non-acute decompensation is the most frequent pathway of the first decompensation, AD mostly represents further decompensation.