Further decompensation in cirrhosis. Results of a large multicenter cohort study supporting Baveno VII statements

Background: The prognostic weight of further decompensation in cirrhosis is still unclear. We investigated the incidence of further decompensation and its effect on mortality in patients with cirrhosis. Methods: Multicenter cohort study. The cumulative incidence of further decompensation (development of a second event or complication of a decompensating event) was assessed using competing risks analysis in 2028 patients. A four-state model was built: first decompensation, further decompensation, liver transplant, death. A cause-specific Cox model was used to assess the adjusted effect of further decompensation on mortality. Sensitivity analyses were performed for patients included before or after 1999. Results: In a mean follow-up of 43 months, 1192 patients developed further decompensation and 649 died. Corresponding 5-year cumulative incidences were 52% and 35%, respectively. The cumulative incidences of death and liver transplant after further decompensation were 55% and 9.7%, respectively. The most common further decompensating event was ascites/complications of ascites. Five-year probabilities of state occupation were: 24% alive with first decompensation, 21% alive with further decompensation, 7% alive with liver transplant, 16% dead after first decompensation without further decompensation, 31% dead after further decompensation, and <1% dead after liver transplant. The hazard ratio for death after further decompensation adjusted for known prognostic indicators, was 1.46 (95% CI 1.23-1-711) (p<0.001). The significant impact of further decompensation on survival was confirmed in patients included before or after 1999. Conclusion: In cirrhosis, further decompensation occurs in approximately 60% of patients, significantly increases mortality, and should be considered a more advanced stage of decompensated cirrhosis.