Decompensation as initial presentation in patients with liver cirrhosis is associated with an increased risk of future decompensation and mortality

Figures & data

Figure 1. Flowchart of included patients. From the 1697 identified patients, 868 records were screened and 681 patients were included in analyses.

Table 1. Patients presenting at diagnosis of cirrhosis: comparing compensated and decompensated patients.

Initial presentation		Compensated (n = 403)	Decompensated (n = 267)
Age at diagnosis		57 ± 12	58 ± 12	p = 0.49
Gender M/F		68%/32%	66%/34%	p = 0.60
Aetiology	Alcoholic	138 (34%)	189 (71%)	p < 0.01
	Viral hepatitis	140 (35%)	33 (12%)	p < 0.01
	Cholestatic	17 (4%)	10 (4%)	p = 0.84
	Autoimmune	23 (6%)	7 (3%)	p = 0.08
	NAFLD/NASH	73 (18%)	23 (9%)	p < 0.01
	Cryptogenic	28 (7%)	9 (3%)	p = 0.06
MELD score	<9	175 (44%)	45 (17%)
	10–19	104 (26%)	129 (48%)
	20–29	18 (5%)	35 (13%)
	30–39	–	10 (4%)
	Missing	105 (26%)	47 (18%)
CP	A	219 (55%)	37 (14%)
	B	53 (13%)	100 (38%)
	C	9 (2%)	64 (24%)
	Missing	121 (30%)	66 (25%)
Decompensated presentation		Ascites	176 (62%)
		Variceal bleeding	41 (15%)
		Ascites + variceal bleeding	11 (4%)
		Hepatic Encephalopathy	9 (3%)
Decompensations after the initial presentation	(mean ± SD)	1.61 (± 2.48)	2.73 (± 2.68)	p < 0.01

Decompensated patients more often had alcoholic cirrhosis (71% vs 34%, p < 0.01), less often viral hepatitis or NAFLD/NASH (12% vs 35%, p < 0.01; 9% vs 18%, p < 0.01) and had more decompensation episodes after the initial presentation (2.73 vs 1.61, p < 0.01).

Figure 2. Transplant-free survival. Patients presenting with decompensated liver cirrhosis had a median survival of 86 months compared to 136 months for patients with compensated liver cirrhosis (p < 0.01) using the Log Rank test.

Table 2. Risk factors, univariate and multivariate for mortality in cirrhotic patients.

Mortality risk
		Univariate		Multivariate
		HR (95% CI)		aHR (95% CI)
Age	per year	1.06 (1.04–1.07)	p < 0.01	1.07 (1.05–1.09)	p < 0.01
Gender	male vs female	0.96 (0.75–1.22)	p = 0.72
Etiology	alcoholic vs non-alcoholic	1.77 (1.39–2.25)	p < 0.01	1.10 (0.78–1.56)	p = 0.58
Smoking	yes vs no	1.53 (1.19–1.96)	p < 0.01	1.83 (1.35–2.48)	p < 0.01
High risk comorbidity	yes vs no	1.55 (1.22–1.98)	p < 0.01	1.09 (0.79–1.49)	p = 0.61
Initial presentation	decompensated vs compensated	1.85 (1.45–2.34)	p < 0.01	1.43 (1.03–1.98)	p = 0.04
MELD	per point increase	1.06 (1.04–1.08)	p < 0.01	1.07 (1.04–1.09)	p < 0.01
PPI use	yes vs no	1.74 (1.35–2.24)	p < 0.01	1.35 (0.99–1.82)	p = 0.05
Statin use	yes vs no	1.53 (1.16–2.00)	p < 0.01	0.96 (0.66–1.40)	p = 0.07

In multivariate analysis, age (aHR 1.07, p < 0.01), smoking (aHR 1.83, p < 0.01), initial presentation as decompensated cirrhosis (aHR 1.43, p = 0.04) and MELD score (aHR 1.07, p < 0.01) increased the risk of mortality.

Table 3. Risk factors, univariate and multivariate for future decompensation in cirrhotic patients.

Risk for future decompensation
		Univariate		Multivariate
		HR (95% CI)		aHR (95% CI)
Age	per year	1.02 (1.01–1.03)	p < 0.01	1.02 (1.01–1.03)	p < 0.01
Gender	male vs female	1.12 (0.90–1.40)	p = 0.31
Etiology	alcoholic vs non-alcoholic	1.44 (1.16–1.78)	p < 0.01	1.34 (1.01–1.76)	p = 0.04
Smoking	yes vs no	1.06 (0.85–1.31)	p = 0.63
High risk comorbidity	yes vs no	1.15 (0.93–1.43)	p = 0.20
Initial presentation	decompensated vs compensated	1.40 (1.14–1.73)	p < 0.01	1.37 (1.03–1.82)	p = 0.03
MELD	per point increase	1.04 (1.02–1.06)	p < 0.01	1.02 (0.99–1.05)	p = 0.08
PPI use	yes vs no	1.25 (1.01–1.55)	p < 0.05	1.16 (0.90–1.50)	p = 0.26
Statin use	yes vs no	1.28 (0.99–1.64)	p = 0.05

In multivariate analysis, age (aHR 1.02, p < 0.01), alcoholic cirrhosis (aHR 1.34, p = 0.04) and initial presentation with decompensated cirrhosis (aHR 1.37, p = 0.03) increased the risk of future decompensation.

Figure 3. Transplant-free survival (TFS) after HCC diagnosis. Median TFS was 48 months in appropriately screened patients compared to 22 months in patients who weren’t screened according to guidelines (p < 0.01) using the Log Rank test.