A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis

Background and aimsThe bad prognosis of Acute Decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined Non-Acute Decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis.Patients and Methods617 cirrhotic outpatients from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic.ResultsDuring follow-up, 154 patients (25.0% of total patients) developed no complications, 69 patients (44.8%) developed NAD and 85 (55.2%) AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation (ND) than in patients with NAD or AD. At multivariable analysis, AD (HR 21.07, p<0.001), NAD (HR 7.13, p<0.001), the etiological cure of cirrhosis (HR 0.38, p<0.001) and MELD (HR 1.12, p=0.003) were found as independent predictors of mortality.ConclusionsIn almost 50% outpatients the first decompensation is a NAD, which is associated with a decreased survival than patients with ND. Patients who develop NAD must be treated with extreme care and monitored closely to prevent any development of AD.Impact and implicationsThis multicenter study is the first to investigate the role of NAD in patients with cirrhosis. In fact, while the unfavorable impact of AD is well known, NAD is currently a phenomenon existing in clinical practice but never studied. Our data show that almost half of the decompensations in patients with cirrhosis are attributable to NAD and that this involves a higher risk of mortality compared to compensated patients. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality.