Recompensation in Cirrhosis: Current Evidence and Future Directions

Role of etiological therapy in achieving recompensation of decompensated liver cirrhosis

The traditional view of the decompensated stage as a point of no return in the natural history of liver cirrhosis (LC) is currently being questioned. This is due to the appearance of data indicating the possibility of restoring the structure and function of the liver, reducing the portal pressure with a positive effect on complications associated with portal hypertension and decreasing the risk of developing hepatocellular carcinoma after elimination of the etiological factor. To create a unified understanding the recompensation of decompensated LC, at the Baveno VII consensus workshop were developed criteria confirming it. At the moment, the efficacy of etiological therapy in achieving established criteria for recompensation has been evaluated only in patients with alcohol-related, as well as hepatitis B virus-related and hepatitis C virus-related decompensated LC. The purpose of the review is to provide up-to-date information on the role of etiological therapy in achieving recompensation of decompensated LC according to Baveno VII criteria. So far, only the first steps have been taken in studying this problem. To further understand it, research is needed to identify pathophysiological mechanisms, modifying factors, predictors, and potential noninvasive biomarkers of recompensation of decompensated LC.

Application of Interpretable Machine Learning Models to Predict the Risk Factors of HBV-Related Liver Cirrhosis in CHB Patients Based on Routine Clinical Data: A Retrospective Cohort Study

Chronic hepatitis B (CHB) infection represents a significant global public health issue, often leading to hepatitis B virus (HBV)-related liver cirrhosis (HBV-LC) with poor prognoses. Early identification of HBV-LC risk is essential for timely intervention. This study develops and compares nine machine learning (ML) models to predict HBV-LC risk in CHB patients using routine clinical and laboratory data. A retrospective analysis was conducted involving 777 CHB patients, with 50.45% (392/777) progressing to HBV-LC. Admission data consisted of 52 clinical and laboratory variables, with missing values addressed using multiple imputation. Feature selection utilized Least Absolute Shrinkage and Selection Operator (LASSO) regression and the Boruta algorithm, identifying 24 key variables. The evaluated ML models included XGBoost, logistic regression (LR), LightGBM, random forest (RF), AdaBoost, Gaussian naive Bayes (GNB), multilayer perceptron (MLP), support vector machine (SVM), and k-nearest neighbors (KNN). The data set was partitioned into an 80% training set (n = 621) and a 20% independent testing set (n = 156). Cross-validation (CV) facilitated hyperparameter tuning and internal validation of the optimal model. Performance metrics included the area under the receiver operating characteristic curve (AUC), Brier score, accuracy, sensitivity, specificity, and F1 score. The RF model demonstrated superior performance, with AUCs of 0.992 (training) and 0.907 (validation), while the reconstructed model achieved AUCs of 0.944 (training) and 0.945 (validation), maintaining an AUC of 0.863 in the testing set. Calibration curves confirmed a strong alignment between observed and predicted probabilities. Decision curve analysis indicated that the RF model provided the highest net benefit across threshold probabilities. The SHAP algorithm identified RPR, PLT, HBV DNA, ALT, and TBA as critical predictors. This interpretable ML model enhances early HBV-LC prediction and supports clinical decision-making in resource-limited settings.

The Natural History of Hepatitis C Virus Infection and Disease in the Era of Curative Therapy with Direct-Acting Antivirals

The availability of highly effective direct-acting antivirals (DAAs) that cure individuals infected with HCV has changed completely the natural history of HCV infection and chronic hepatitis C. In sustained responders to DAAs, the most common clinical-pathologic outcome has become liver disease regression, cirrhosis re-compensation, and the de-listing of transplant candidates. However, careful scrutiny of liver disease cofactors and outcome predictors in treated patients is mandatory for an appropriate personalized surveillance of the residual risk for hepatocellular carcinoma. Since successful treatment with DAAs does not confer protective immunity against HCV reinfection, an effective vaccine is critically needed to control HCV infection. Meanwhile, it is mandatory to enhance universal access to DAAs, to test asymptomatic high-risk groups who are the main source of transmission, and to screen people who inject drugs (PWID), men who have sex with men (MSM), and sex workers, and to assure safe medical procedures with the provision of disposable needle and syringes.

Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the “APASL ACLF Research Consortium (AARC)” was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia–Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the ‘Golden Therapeutic Window’, the ‘transplant window’, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The ‘Kyoto APASL Consensus’ presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Recompensation in MASLD-related cirrhosis via metabolic bariatric surgery

The prognosis of patients with decompensated cirrhosis is poor, with significantly increased liver-related mortality rates. With the rising tide of decompensated cirrhosis associated with metabolic dysfunction-associated steatotic liver disease (MASLD), the role of metabolic bariatric surgery (MBS) in achieving hepatic recompensation is garnering increasing attention. However, the complexity of preoperative assessment, the risk of postoperative disease recurrence, and the potential for patients to experience surgical complications of the MBS present challenges. In this opinion article we analyze the potential of MBS to induce recompensation in MASLD-related cirrhosis, discuss the mechanisms by which MBS may affect recompensation, and compare the characteristics of different MBS procedures; we highlight the therapeutic potential of MBS in MASLD-related cirrhosis recompensation and advocate for research in this complex area.

Acute-on-chronic liver failure (ACLF): the 'Kyoto Consensus'-steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Recompensation of Chronic Hepatitis C-Related Decompensated Cirrhosis Following Direct-Acting Antiviral Therapy: Prospective Cohort Study From a Hepatitis C Virus Elimination Program

BACKGROUND & AIMS

Chronic hepatitis C-related decompensated cirrhosis is associated with lower sustained virologic response (SVR)-12 rates and variable regression of disease severity after direct-acting antiviral agents. We assessed rates of SVR-12, recompensation (Baveno VII criteria), and survival in such patients.

METHODS

Between July 2018 and July 2023, patients with decompensated chronic hepatitis C-related cirrhosis after direct-acting antiviral agents treatment were evaluated for SVR-12 and then had 6-monthly follow-up.

RESULTS

Of 6516 patients with cirrhosis, 1152 with decompensated cirrhosis (age 53.2 ± 11.5 years; 63% men; Model for End-stage Liver Disease-Sodium [MELD-Na]: 16.5 ± 4.6; 87% genotype 3) were enrolled. SVR-12 was 81.8% after 1 course; ultimately SVR was 90.8% after additional treatment. Decompensation events included ascites (1098; 95.3%), hepatic encephalopathy (191; 16.6%), and variceal bleeding (284; 24.7%). Ascites resolved in 86% (diuretic withdrawal achieved in 24% patients). Recompensation occurred in 284 (24.7%) at a median time of 16.5 (interquartile range, 14.5-20.5) months. On multivariable Cox proportional hazards analysis, low bilirubin (adjusted hazard ratio [aHR], 0.6; 95% confidence interval [CI], 0.5-0.8; P < 0.001), international normalized ratio (aHR, 0.2; 95% CI, 0.1-0.3; P < 0.001), absence of large esophageal varices (aHR, 0.4; 95% CI, 0.2-0.9; P = 0.048), or gastric varices (aHR, 0.5; 95% CI, 0.3-0.7; P = 0.022) predicted recompensation. Portal hypertension progressed in 158 (13.7%) patients, with rebleed in 4%. Prior decompensation with variceal bleeding (aHR, 1.6; 95% CI, 1.2-2.8; P = 0.042), and presence of large varices (aHR, 2.9; 95% CI, 1.3-6.5; P < 0.001) were associated with portal hypertension progression. Further decompensation was seen in 221 (19%); 145 patients died and 6 underwent liver transplantation. A decrease in MELDNa of ≥3 was seen in 409 (35.5%) and a final MELDNa score of <10 was seen in 335 (29%), but 2.9% developed hepatocellular carcinoma despite SVR-12.

CONCLUSIONS

SVR-12 in hepatitis C virus-related decompensated cirrhosis in a predominant genotype 3 population led to recompensation in 24.7% of patients over a follow-up of 4 years in a public health setting. Despite SVR-12, new hepatic decompensation evolved in 19% and hepatocellular carcinoma developed in 2.9% of patients. (ClinicalTrials.gov, Number: NCT03488485).

Microbiota and Long-Term Prognosis in Liver Cirrhosis

   Purpose. To compare the gut microbiota in patients with an anamnesis of liver cirrhosis of less than and more than 10 years.

   Materials and methods. A one-stage study and metagenomic fecal sequencing of 40 hospitalized patients with liver cirrhosis were conducted, of which 35 were with a history of cirrhosis of less than 10 years and 5 — more than 10 years. High-throughput sequencing was performed using a MiSeq genetic analyzer (Illumina, USA) and a protocol based on analysis of 16s rRNA gene variable regions. The study was registered in Clinicaltrials.gov (NCT05335213). Data analysis was performed using Kraken2 algorithm. The analysis of the difference in the proportional composition of the microbiome between the groups was carried out using polynomial Dirichlet modeling (Likelihood-Ratio-Test Statistics: Several Sample Dirichlet-Multinomial Test Comparison), the Mann-Whitney test with preliminary data transformation by CLR transformation (Centered log ratio transform), differential analysis of gene expression based on negative binomial distribution (DESeq2). The significance level α assumed to be 0.05.

   Results. In patients with liver cirrhosis, the dominant phylotypes of fecal microbiota are Firmicutes, Bacteroidetes, Proteobacteria, Actinobacteria, minor components include taxa Aquificae, Coprothermobacterota, Tenericutes, Verrucomicrobia, Chloroflexi, Deinococcus-Thermus, Thermotogae, Chlorobi. Significant differences have been established in the density of dominant and minor philotypes of gut bacteria, such as Actinobacteria, Proteobacteria, Tenericutes, Coprothermobacterota, as well as some classes, genera, bacterial species in patients with different disease duration (p < 0.05).

   Conclusion. There is no doubt about the effect of gut microbiota on compensation for liver function. The established differences in the composition of the microbiota in patients with liver cirrhosis depending on survival over 10 years are of scientific and practical importance for the formation of an evidence-based approach to the use of microbiome-associated interventions

Nicotine promotes development of bile duct ligation-induced liver fibrosis by increasing expression of nicotinic acetylcholine receptors in rats

Aim of the study

Liver fibrosis and cigarette smoking seem to be directly linked. Nicotine, as an agonist of nicotinic acetylcholine receptors (nAChRs), induces many downstream signaling pathways. The pathways through which nicotine affects the process of liver fibrosis have not been clarified. The present study aimed to investigate the nicotine-induced effects on fibrosis progression in cholestatic rats.

Material and methods

First, the Wistar rats were subjected to sham or bile duct ligation (BDL) surgery. The rats were treated with low and high doses of nicotine (1 or 10 mg/kg) for three weeks. They were monitored for their body weights before and 21 days after BDL. Also, spleens were weighed to calculate the spleen/body weight ratio. Ductular proliferation and fibrosis were evaluated using hematoxylin and eosin (H&E) as well as Masson's trichrome staining. The mRNA expression of α4nAChR, α7nAChR, and fibrosis gene α-smooth muscle actin (α-SMA) was measured by real-time PCR.

Results

The findings showed that nicotine promotes the development of BDL-induced liver fibrosis. The ratio of spleen/body weight was significantly affected by nicotine exposure. H&E and Masson's trichrome staining showed that the level of liver fibrosis was higher in the cholestatic BDL groups, and this effect was significantly augmented in the nicotine-treated rats. Also, α4nAChR, α7nAChR, and α-SMA expression was observed in the BDL rats and increased following nicotine treatment.

Conclusions

The activation of nAChR triggers biliary proliferation and liver fibrosis. Studying the intracellular mechanism of nicotine and alteration in the expression of nicotinic receptors following nicotine exposure can be useful both in diagnosing nicotine-related diseases and finding new treatment strategies.

Recompensation in cirrhosis: unravelling the evolving natural history of nonalcoholic fatty liver disease

Recompensation has gained increasing attention in the field of cirrhosis, particularly in chronic liver disease with a definite aetiology. The current global prevalence of obesity and nonalcoholic fatty liver disease (NAFLD) is increasing, but there is currently a lack of a clear definition for recompensation in NAFLD-related cirrhosis. Here, we provide an up-to-date perspective on the natural history of NAFLD, emphasizing the reversible nature of the disease, summarizing possible mechanisms underlying recompensation in NAFLD, discussing challenges that need to be addressed and outlining future research directions in the field. Recompensation is a promising goal in patients with NAFLD-related cirrhosis, and further studies are needed to explore its underlying mechanisms and uncover its clinical features.

Risk of HCC decreases in HBV-related patients with cirrhosis acquired recompensation: A retrospective study based on Baveno VII criteria

BACKGROUND

Antiviral therapy improves the clinical outcomes of patients with HBV-related cirrhosis. In this study, we aimed to evaluate the incidence rate of HCC in patients with HBV-related recompensated, compensated, or decompensated cirrhosis based on the latest Baveno VII criteria.

METHODS

In this two-center retrospective study, HBV-related patients with cirrhosis were enrolled and treated with first-line nucleos(t)ide analogues therapy for at least 12 months. Participants were classified into 3 groups: (1) compensated group, (2) decompensated group, or (3) recompensated group according to Baveno VII criteria. Multivariate regression models and propensity score matching were used to identify the predictors of HCC.

RESULTS

Of the 404 patients recruited, during a median follow-up of 44.5 months (interquartile range 26.8, 57.0 months), 233 (57.7%), 100 (24.8%), and 71(17.6%) patients had compensated, recompensated, and decompensated cirrhosis. In total, 38 developed HCC. The cumulative incidence of HCC development at 2, 4, and 6 years was 1.3%, 5.4%, and 20.0% in the compensated group, 1.2%, 5.2%, and 24.5% in the recompensated group, and 2.1%, 23.6%, and 41.8% in the decompensated group, respectively. In the multivariate Cox regression model, compared with the recompensated group, the decompensated group had a significant increased risk for the development of HCC (aHR 2.55; 95% CI: 1.240-5.240; p = 0.027), while the compensated group had similar HCC risk for the development of HCC (aHR 1.41; 95% CI: 0.540-3.730; p = 0.835). Propensity score-matching analysis between the recompensated and compensated groups (84 pairs) and propensity score-matching analysis between the recompensated and decompensated groups (62 pairs) showed similar results.

CONCLUSIONS

Achieving recompensation reduced the risk of HCC in patients with HBV-related decompensated cirrhosis, while the risk remained comparable to that of compensated cirrhosis.

Global Epidemiology of Cirrhosis: Changing Etiological Basis and Comparable Burden of Nonalcoholic Steatohepatitis between Males and Females

INTRODUCTION

The etiology of liver diseases has changed significantly, but its impact on the comparative burden of cirrhosis between males and females is unclear. We estimated sex differences in the burden of cirrhosis across 204 countries and territories from 2010 to 2019.

METHODS

We analyzed temporal trends in the burden of cirrhosis using the methodology framework of the 2019 Global Burden of Disease study. We estimated annual frequencies and age-standardized rates (ASRs) of cirrhosis incidence, death, and disability-adjusted life-years (DALYs) by sex, region, country, and etiology.

RESULTS

In 2019, the frequency of incident cases, deaths, and DALYs due to cirrhosis was 1,206,125, 969,068, and 31,781,079 in males versus 845,429, 502,944, and 14,408,336 in females, respectively. From 2010 to 2019, the frequency of cirrhosis deaths increased by 9% in males and 12% in females. Incidence ASRs remained stable in males but increased in females, while death ASRs declined in both. Death ASRs for both sexes declined in all regions, except in the Americas where they remained stable. In 2019, alcohol was the leading cause of cirrhosis deaths in males, and hepatitis C in females. Death ASRs declined for all etiologies in both sexes, except in nonalcoholic steatohepatitis (NASH). The ratio of female-to-male incidence ASRs in 2019 was lowest in alcohol(0.5), and highest in NASH(1.3), while the ratio of female-to-male death ASRs was lowest in alcohol(0.3) and highest in NASH(0.8).

CONCLUSION

The global burden of cirrhosis is higher in males. However, incidence and death ASRs from NASH cirrhosis in females are comparable to that of males.