Prognostic assessment of liver cirrhosis and its complications: current concepts and future perspectives

Abstract

Liver cirrhosis is an irreversible stage of chronic liver disease with varying clinical course. Acute decompensation of liver cirrhosis represents a watershed in prognosis and is characterized by the occurrence of clinical complications such as ascites, jaundice, hepatic encephalopathy, infections, or portal-hypertensive hemorrhages. Emergent data indicate that an acute decompensation can be subdivided into stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-acute-on chronic liver failure (pre-ACLF) and acute-on chronic liver failure (ACLF), while the mortality risk varies greatly between the respective subgroups. ACLF is the most severe form of acutely decompensated cirrhosis and characterized by the development of organ failure(s) and a high short-term mortality. Due to the dynamic disease course of acute decompensation, it is paramount to detect patients at particular risk for severe complications those at high risk for developing ACLF as early as possible in order to initiate optimal management. This review describes new concepts and perspectives in the definition and classification of decompensated cirrhosis and provides on overview on emerging predictive scoring systems, non-invasive measurement methods and new biomarkers, which allow an early identification of patients with acute decompensation at risk.

Keywords: ACLF; AD; LSM; SSM; cirrhosis; portal hypertension; prognosis; scoring systems.

Figure 1

Overview of the different stages of liver cirrhosis. CC, compensated cirrhosis; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis; pre-ACLF, pre-acute-on-chronic liver failure; ACLF, acute-on-chronic liver failure.

Figure 2

(A) A proposed algorithm for using the EASL CLIF-Consortium predictive score scoring systems for identifying cirrhotic patients with AD and ACLF [modified from Jalan et al. (22)]. The following formulas are used for calculation: CLIF-C Acute-on-chronic liver failure (CLIF-C ACLF) formula: CLIF ACLF score = 10 × (0.33 × CLIF-OF score + 0.44 × Age [years] + 0.63 × ln(WBC [109/L] − 2) (23); CLIF-C Acute decompensation (CLIF-C AD) formula: CLIF-C AD score = (10 × 0.03 × Age [years]) + (0.66 × ln(SCr [mg/dL]) + 1.71 × ln(INR) + 0.88 × ln(WBC [109/L]) − 0.05 × Na [mmol/L] + 8 (22). (B) Overview of the Chronic Liver Failure-Consortium Organ Failure scale ()-score with definition criteria for organ failure. Shadowed areas define criteria for the diagnosis of organ failure. HE, Hepatic encephalopathy; FiO2, fraction of inspired oxygen; PaO2, partial pressure of arterial oxygen; SpO2, pulse oximetric saturation.