Mortality Risk According to Different Clinical Characteristics of First Episode of Liver Decompensation in Cirrhotic Patients: A Nationwide, Prospective, 3-Year Follow-Up Study in Italy

Abstract

The occurrence of decompensation marks a crucial turning point in the course of cirrhosis. The purpose of this study was to assess the risk of mortality according to the clinical characteristics of fi rst decompensation, considering also the impact of acute-on-chronic liver failure (AoCLF). METHODS:We conducted a prospective nationwide inception cohort study in Italy. Decompensation was defi ned by the presence of ascites, either overt or detected by ultrasonography (UD), gastroesophageal variceal bleeding (GEVB), and hepatic encephalopathy (HE). AoCLF was defi ned according to the Asian Pacifi c Association for the Study of the Liver criteria. Multivariable Cox proportional hazards regression was used to analyze the risk of failure (death or orthotopic liver transplantation (OLT)). RESULTS:A total of 490 consecutive cirrhotic patients (314 males, mean age 60.9 ± 12.6 years) fulfi lled the study criteria. AoCLF was identifi ed in 59 patients (12.0 % ). Among the remaining 431 patients, ascites were found in 330 patients (76.6 % ): in 257 (77.8 % ) as overt ascites and in 73 (22.2 % ) as UD ascites. GEVB was observed in 77 patients (17.9 % ) and HE in 30 patients (7.0 % ). After a median follow-up of 33 months, 24 patients underwent OLT and 125 died. The cumulative incidence of failure (death or OLT) after 1, 2, and 3 years was, respectively, 28, 53, and 62 % in patients with AoCLF; 10, 18, and 25 % in patients with UD ascites; 17, 31, and 41 % in patients with overt ascites; and 8, 12, and 24 % in patients with GEVB ( P < 0.0001).CONCLUSIONS: AoCLF is responsible for a relevant proportion of fi rst decompensation in cirrhotic patients and is associated with the poorest outcome. Patients with UD ascites do not have a negligible mortality rate and require clinical monitoring similar to that of patients with overt ascites .SUPPLEMENTARY MATERIAL is linked to the online version of the paper at

Single‐centre validation of the EASL‐CLIF Consortium definition of acute‐on‐chronic liver failure and CLIF‐SOFA for prediction of mortality in cirrhosis

“…These results were expected as the EASL‐CLIF Consortium definition of ACLF was based on variables classically related to prognosis in cirrhotics and non‐cirrhotics patients, and was developed with very restrictive thresholds for diagnosis of organ failure . Ascites is also an important prognostic marker in cirrhosis and in the context of acute decompensation is probably an indicator of more advanced liver disease . Supporting our findings, the CANONIC study showed that ascites at enrolment was a risk factor for post‐enrolment development of ACLF , probably reflecting the close relationship between the presence of ascites and the risk of renal failure in cirrhosis .…”

Increased delayed mortality in patients with acute‐on‐chronic liver failure who have prior decompensation

“…Non‐hepatic insults were classified as acute precipitating events only after hepatic acute events had been excluded. Overt ascites was diagnosed by clinical examination and ultrasonography as previously described . HE was defined as an episode of neurological and neuropsychiatric abnormality …”

Varices and Variceal Hemorrhage in Cirrhosis: A New View of an Old Problem

“…As already mentioned, the recent Baveno workshop stated that prevention of decompensation is probably more appropriate as an end-point in this group as well, since bleeding is not the most frequent decompensating event (it is usually ascites) and patients with varices are more likely to decompensate than those without varices 22 . Considering only the bleeding episodes as relevant outcomes ignores the profound impact that developing ascites or encephalopathy before bleeding has on the prognosis of cirrhosis 12, 23, 24 . This new approach implies that treatments for this stage should be able to prevent all complications of portal hypertension.…”