Hepatic recompensation according to Baveno VII criteria is linked to a significant survival benefit in decompensated alcohol‐related cirrhosis

Abstract

Background & AimsRemoving the primary aetiological factor in decompensated cirrhosis may lead to a restoration of hepatic function. In this study, we investigated the clinical implications of recompensation and the subsequent survival in patients with decompensated alcohol‐related cirrhosis.MethodsThe rate of recompensation was evaluated in patients with decompensated alcohol‐related cirrhosis and persistent alcohol abstinence undergoing a hepatic venous pressure gradient (HVPG) measurement. Recompensation was defined according to Baveno VII criteria as resolution of ascites and hepatic encephalopathy, absence of variceal bleeding and improvement in liver function.ResultsTwo hundred and four abstinent patients with decompensated alcohol‐related cirrhosis (age: 57.2 [IQR:50.1–63.7] years; 75.0% male; median MELD: 15 [IQR:11–19]) and a median HVPG of 20 (IQR:18–24) mmHg were included. During a median follow‐up of 24.4 (IQR:10.9–50.4) months, 37 patients (18.1%) achieved abstinence‐induced recompensation. Lower baseline HVPG, lower Child‐Pugh score, lower BMI, higher albumin and higher mean arterial pressure were linked to a higher probability of recompensation. After adjusting for age, disease severity, portal hypertension and systemic inflammation, achieving recompensation resulted in a significant and considerable reduction in liver‐related mortality (adjusted HR: 0.091 [95% CI: 0.012–0.677]; p = .019). Only 13 patients (6.4%) developed hepatocellular carcinoma, with a tendency towards a lower risk upon recompensation (HR: 0.398 [95% CI: 0.084–1.878]; p = .245), yet this finding did not reach statistical significance and requires further investigation.ConclusionsAlcohol abstinence led to recompensation in 18.1% of our cohort of HVPG‐characterised patients with decompensated alcohol‐related cirrhosis. Achieving hepatic recompensation resulted in a >90% risk reduction in liver‐related mortality.

Evaluation of potential hepatic recompensation criteria in patients with PBC and decompensated cirrhosis

“…In this study, we provide first insights into the possibility of hepatic recompensation in patients with decompensated PBC. We observed that recompensation can be achieved in up to 17% of all patients with PBC, which is comparable to the rate observed in alcohol‐related cirrhosis following persistent abstinence, 32 yet considerably lower than the rate reported for patients with viral hepatitis B receiving nucleoside analogon therapy 33 . These discrepancies may be explained by the almost universal effectiveness of nucleoside analogues to suppress hepatitis B replication, while Paris II criteria are less often achieved with UDCA.…”

“…While this finding stands in contrast with our observations, our study was not limited to transplant candidates and may therefore provide more precise insights into the possibility of recompensation in a more representative cohort of patients with PBC with dACLD. In this regard, it should also be noted that the median MELD‐Na was only 13.5 in our study and that less advanced hepatic dysfunction increases the chance of hepatic recompensation 23,32 …”

“…A successful therapy of the underlying liver disease aetiology has been shown to not only induce regression of fibrosis 19 and portal hypertension 30,31 but also to improve liver function and to enable the delisting of a subset of decompensated liver transplant candidates 21,22,24,32 . These observations have challenged the irreversibility of dACLD and have led to the introduction of novel criteria for the definition of hepatic recompensation by the Baveno VII faculty 25 .…”

Meta‐analysis: Prevalence and impact of alcohol abstinence in alcohol‐associated cirrhosis

“…[62][63][64] These findings underscore the urgent need for the implementation of multidisciplinary strategies that effectively engage and address the needs of this special population and support them in achieving sustained alcohol abstinence. 65,66 These data should be validated in large, prospective studies that account for the time-varying nature of alcohol use with long-term follow-up. Although alcohol abstinence was not associated with a reduction in the development of HCC, this may be related to the limited number of studies available, and more studies are required.…”

Defining recompensation of alcohol‐related liver disease: A step beyond decompensated cirrhosis

“…In this context, the study by Hofer and colleagues in Liver International is of great interest, 11 as it defines the phenomenon of recompensation in a large cohort of patients with alcohol‐related decompensated cirrhosis. The investigators included a well‐characterized cohort of patients with baseline portal pressure gradient measurement.…”