Acute and non-acute decompensation of liver cirrhosis (47/130)

Abstract

In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.

Keywords: ACLF; acute decompensation; acute‐on‐chronic liver failure; liver cirrhosis; non‐acute decompensation.

FIGURE 1

Figure displays the newly proposed pathways of acute decompensation (AD) and non‐acute decompensation (NAD). These clinical pathways are distinctly characterised by the velocity, severity and clinical urgency of the occurring event(s). Non‐elective/emergency hospitalisation due to decompensation that occurs may represent a viable stratum to distinguish AD from NAD since it implies clinical relevance and urgency for medical intervention. While NAD features a slow and progressive development of complications, AD is characterised by a more severe and accelerated clinical course, leading to the development of its distinct sub‐phenotypes and, frequently, progression towards acute‐on‐chronic liver failure (ACLF). Othotopic liver transplantation (OLT) can represent a potentially life‐saving treatment option for ACLF patients, who otherwise present high mortality rates. In patients with a less severe clinical course and/or patients with ACLF resolution, the NAD pathway may also constitute a transitioning hub to a state of recompensated cirrhosis. This figure was adapted and modified from D'Amico et al. 10.1016/j.jhep.2021.06.018