Skip to main content

Advertisement

SpringerLink
Log in

Prognostic Factors in Compensated and Decompensated Cirrhosis

  • Portal Hypertension (JC Garcia-Pagán, Section Editor)
  • Published:
Current Hepatology Reports Aims and scope Submit manuscript

Abstract

There are an increasing number of studies that evaluate predictive factors, mostly of death, in cirrhosis. These are different depending on the presence of compensated or decompensated cirrhosis. In compensated cirrhosis the main event to predict is decompensation. The degree of portal hypertension as determined by the hepatic venous pressure gradient (HVPG) and serum albumin levels are the most relevant predictors of decompensation. Since HVPG determination is obtained through an invasive procedure, recent studies have examined alternative non-invasive methods to establish the presence of clinically significant portal hypertension. In decompensated cirrhosis the main event to predict is death and “further decompensation”, the event that most commonly occurs prior to death. The Child and MELD scores are the most important predictors of death in decompensated disease. Child score continues to be a useful stratifying tool in all patients with cirrhosis. Specific predictive factors in each type of clinical decompensation are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217–31.

    Article  PubMed  Google Scholar 

  2. Zipprich A, Seufferlein T, Dollinger MM. Subclinical ascites defines an intermediate stage between compensated and decompensated cirrhosis. Z Gastroenterol. 2012;50:996–1001.

    Article  CAS  PubMed  Google Scholar 

  3. Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013;144:1426–37, 37 e1-9.

  4. Zipprich A, Garcia-Tsao G, Rogowski S, Fleig WE, Seufferlein T, Dollinger MM. Prognostic indicators of survival in patients with compensated and decompensated cirrhosis. Liver Int. 2012;32:1407–14.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Bruno S, Saibeni S, Bagnardi V, et al. Mortality risk according to different clinical characteristics of first episode of liver decompensation in cirrhotic patients: a nationwide, prospective, 3-year follow-up study in Italy. Am J Gastroenterol. 2013;108:1112–22. This study evaluates survival of patients with cirrhosis according to the first decompensation. It shows that survival in patients that present with ascites is worse than in those that present with variceal hemorrhage, with worst survival in those with “acute-on-chronic” liver failure.

    Article  PubMed  Google Scholar 

  6. Liaw YF, Sung JJ, Chow WC, et al. Lamivudine for patients with chronic hepatitis B and advanced liver disease. N Engl J Med. 2004;351:1521–31.

    Article  CAS  PubMed  Google Scholar 

  7. Bruno S, Stroffolini T, Colombo M, et al. Sustained virological response to interferon-alpha is associated with improved outcome in HCV-related cirrhosis: a retrospective study. Hepatology. 2007;45:579–87.

    Article  CAS  PubMed  Google Scholar 

  8. D'Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19:475–505.

    Article  PubMed  Google Scholar 

  9. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004;40:652–9.

    Article  PubMed  Google Scholar 

  10. Salerno F, Camma C, Enea M, Rossle M, Wong F. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology. 2007;133:825–34.

    Article  CAS  PubMed  Google Scholar 

  11. Salerno F, Navickis RJ, Wilkes MM. Albumin infusion improves outcomes of patients with spontaneous bacterial peritonitis: a meta-analysis of randomized trials. Clin Gastroenterol Hepatol. 2013;11:123–30 e1.

    Article  CAS  PubMed  Google Scholar 

  12. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hepatocellular carcinoma. N Engl J Med. 2008;359:378–90.

    Article  CAS  PubMed  Google Scholar 

  13. D'Amico G, Morabito A, Pagliaro L, Marubini E. Survival and prognostic indicators in compensated and decompensated cirrhosis. Dig Dis Sci. 1986;31:468–75.

    Article  PubMed  Google Scholar 

  14. Berzigotti A, Garcia-Tsao G, Bosch J, et al. Obesity is an independent risk factor for clinical decompensation in patients with cirrhosis. Hepatology. 2011;54:555–61. This study is the first to identify obesity as an independent risk factor of decompensation in compensated patients with cirrhosis and portal hypertension but without varices. It is important because obesity is a “fixable” cause of decompensation compared to other factors identified such as portal pressure and serum albumin.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Bruno S, Zuin M, Crosignani A, et al. Predicting mortality risk in patients with compensated HCV-induced cirrhosis: a long-term prospective study. Am J Gastroenterol. 2009;104:1147–58.

    Article  PubMed  Google Scholar 

  16. Rincon D, Lo Iacono O, Tejedor M, et al. Prognostic value of hepatic venous pressure gradient in patients with compensated chronic hepatitis C-related cirrhosis. Scand J Gastroenterol. 2013;48:487–95.

    Article  CAS  PubMed  Google Scholar 

  17. Groszmann RJ, Garcia-Tsao G, Bosch J, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005;353:2254–61.

    Article  CAS  PubMed  Google Scholar 

  18. Ripoll C, Groszmann R, Garcia-Tsao G, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology. 2007;133:481–8.

    Article  CAS  PubMed  Google Scholar 

  19. Berzigotti A, Gilabert R, Abraldes JG, et al. Noninvasive prediction of clinically significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J Gastroenterol. 2008;103:1159–67.

    Article  CAS  PubMed  Google Scholar 

  20. Castera L, Pinzani M, Bosch J. Non invasive evaluation of portal hypertension using transient elastography. J Hepatol. 2012;56:696–703. This review summarizes the utility of non-invasive tools in the evaluation of clinically significant portal hypertension with special emphasis on measurements of liver stiffness by transient elastography.

    Article  PubMed  Google Scholar 

  21. Berzigotti A, Seijo S, Arena U, et al. Elastography, spleen size, and platelet count identify portal hypertension in patients with compensated cirrhosis. Gastroenterology. 2013;144:102–11 e1. This study shows that a combination of non-invasive tests (liver stiffness by transient elastography, platelet count and spleen size) can accurately classify most patients with clinically significant portal hypertension and varices in patients with compensated cirrhosis.

    Article  PubMed  Google Scholar 

  22. Colecchia A, Montrone L, Scaioli E, et al. Measurement of spleen stiffness to evaluate portal hypertension and the presence of esophageal varices in patients with HCV-related cirrhosis. Gastroenterology. 2012;143:646–54. Innovative study that shows that measurements of spleen stiffness are more useful than measurements of liver stiffness in the non-invasive evaluation of portal hypertension in cirrhosis.

    Article  PubMed  Google Scholar 

  23. Takuma Y, Nouso K, Morimoto Y, et al. Measurement of spleen stiffness by acoustic radiation force impulse imaging identifies cirrhotic patients with esophageal varices. Gastroenterology. 2013;144:92–101 e2. This study shows that measurements of spleen stiffness by another methodology (acoustic radiofrequency impulse) are most useful in ruling out the presence of varices in patients with cirrhosis.

    Article  PubMed  Google Scholar 

  24. Castera L, Garcia-Tsao G. When the spleen gets tough, the varices get going. Gastroenterology. 2013;144:19–22.

    Article  PubMed  Google Scholar 

  25. Ferlitsch M, Reiberger T, Hoke M, et al. von Willebrand factor as new noninvasive predictor of portal hypertension, decompensation and mortality in patients with liver cirrhosis. Hepatology. 2012;56:1439–47.

    Article  CAS  PubMed  Google Scholar 

  26. Lisotti A, Azzaroli F, Buonfiglioli F, et al. Indocyanine green retention test as a noninvasive marker of portal hypertension and esophageal varices in compensated liver cirrhosis. Hepatology. 2014;59:643–50. This study that a noninvasive measurement of liver function/liver flow correlates with hepatic venous pressure gradient and determines cutoff levels of ICG retention at 15 minutes that are useful in ruling in or ruling out the presence of varices.

    Article  CAS  PubMed  Google Scholar 

  27. Nahon P, Ganne-Carrie N, Degos F, et al. Serum albumin and platelet count but not portal prssure are predictive of death in patients with Child-Pugh A hepatitis C virus-related cirrhosis. Gastroenterol Clin Biol. 2005;29:347–52.

    Article  PubMed  Google Scholar 

  28. Ripoll C, Bari K, Garcia-Tsao G. Among clinically available markers, serum albumin predicts death in compensated and decompensated cirrhosis. J Clin Gastroenterol 2014 (submitted).

  29. Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1–85.

    CAS  PubMed  Google Scholar 

  30. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31:864–71.

    Article  CAS  PubMed  Google Scholar 

  31. Freeman Jr RB, Wiesner RH, Harper A, et al. The new liver allocation system: moving toward evidence-based transplantation policy. Liver Transpl. 2002;8:851–8.

    Article  PubMed  Google Scholar 

  32. Said A, Williams J, Holden J, et al. Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease. J Hepatol. 2004;40:897–903.

    Article  PubMed  Google Scholar 

  33. Ripoll C, Banares R, Rincon D, et al. Influence of hepatic venous pressure gradient on the prediction of survival of patients with cirrhosis in the MELD Era. Hepatology. 2005;42:793–801.

    Article  PubMed  Google Scholar 

  34. Zipprich A, Kuss O, Rogowski S, et al. Incorporating indocyanin green clearance into the Model for End Stage Liver Disease (MELD-ICG) improves prognostic accuracy in intermediate to advanced cirrhosis. Gut. 2010;59:963–8.

    Article  PubMed  Google Scholar 

  35. Stauber RE, Wagner D, Stadlbauer V, et al. Evaluation of indocyanine green clearance and model for end-stage liver disease for estimation of short-term prognosis in decompensated cirrhosis. Liver Int. 2009;29:1516–20.

    Article  CAS  PubMed  Google Scholar 

  36. Biggins SW, Rodriguez HJ, Bacchetti P, Bass NM, Roberts JP, Terrault NA. Serum sodium predicts mortality in patients listed for liver transplantation. Hepatology. 2005;41:32–9.

    Article  CAS  PubMed  Google Scholar 

  37. Kim WR, Biggins SW, Kremers WK, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008;359:1018–26.

    Article  CAS  PubMed  Google Scholar 

  38. D'Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38:599–612.

    Article  PubMed  Google Scholar 

  39. Abraldes JG, Villanueva C, Banares R, et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol. 2008;48:229–36.

    Article  PubMed  Google Scholar 

  40. Garcia-Pagan JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010;362:2370–9.

    Article  CAS  PubMed  Google Scholar 

  41. Amitrano L, Guardascione MA, Manguso F, et al. The effectiveness of current acute variceal bleed treatments in unselected cirrhotic patients: refining short-term prognosis and risk factors. Am J Gastroenterol. 2012;107:1872–8. This study shows that patients with variceal hemorrhage still have high mortality, although patients mainly die from liver failure rather than uncontrolled bleeding. The main predictor of 5-day failure being a Child score >10 (i.e. Child C class).

    Article  PubMed  Google Scholar 

  42. Reverter E, Tandon P, Augustin S, et al. A MELD-Based Model to Determine Risk of Mortality Among Patients With Acute Variceal Bleeding. Gastroenterology. 2013. This study shows that the discriminative ability of MELD (compared to other scores) is slightly better for the prediction of death in patients with variceal hemorrhage and by re-calibrating the MELD score they could identify patients at a low (MELD <11) and high (MELD > 19) risk of death.

  43. Muntaner L, Altamirano JT, Augustin S, et al. High doses of beta-blockers and alcohol abstinence improve long-term rebleeding and mortality in cirrhotic patients after an acute variceal bleeding. Liver Int. 2010;30:1123–30.

    Article  CAS  PubMed  Google Scholar 

  44. Feu F, Garcia-Pagan JC, Bosch J, et al. Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis. Lancet. 1995;346:1056–9.

    Article  CAS  PubMed  Google Scholar 

  45. Jairath V, Rehal S, Logan R, et al. Acute variceal haemorrhage in the United Kingdom: Patient characteristics, management and outcomes in a nationwide audit. Dig Liver Dis 2014.

  46. Serste T, Gustot T, Rautou PE, et al. Severe hyponatremia is a better predictor of mortality than MELDNa in patients with cirrhosis and refractory ascites. J Hepatol. 2012;57:274–80. This study shows that severe hyponatremia (≤125 mEq/L) is a better predictor of death in patients with refractory ascites. Severe hyponatremia and the Child score were better predictors of mortality than the MELD-Na, emphasizing that the MELD score fails to reflect the severity of illness in patients with cirrhosis and refractory ascites.

    Article  CAS  PubMed  Google Scholar 

  47. Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology. 2008;48:2064–77.

    Article  CAS  PubMed  Google Scholar 

  48. de Carvalho JR, Villela-Nogueira CA, Luiz RR, et al. Acute kidney injury network criteria as a predictor of hospital mortality in cirrhotic patients with ascites. J Clin Gastroenterol. 2012;46:e21–6.

    Article  PubMed  Google Scholar 

  49. Wong F, O'Leary JG, Reddy KR, et al. New consensus definition of acute kidney injury accurately predicts 30-day mortality in patients with cirrhosis and infection. Gastroenterology. 2013;145:1280–8 e1.

    Article  PubMed  Google Scholar 

  50. Belcher JM, Garcia-Tsao G, Sanyal AJ, et al. Association of AKI with mortality and complications in hospitalized patients with cirrhosis. Hepatology. 2013;57:753–62. This prospective study shows, in a cohort of hospitalized patients, that development of AKI (per AKIN criteria) is associated with a high mortality but that progression of AKI to a higher AKIN stage is associated with a higher mortality than AKIN stage at presentation. This emphasizes the need to prevent progression even in patients with small elevations in creatinine (AKIN stage 1).

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  51. Tsien CD, Rabie R, Wong F. Acute kidney injury in decompensated cirrhosis. Gut. 2013;62:131–7. This study shows, in an outpatient setting that even mild and transient elevations in creatinine (but fulfilling AKIN stage 1 criteria) are associated with a higher mortality compared to patients who did not develop any AKI.

    Article  PubMed  Google Scholar 

  52. Fagundes C, Barreto R, Guevara M, et al. A modified acute kidney injury classification for diagnosis and risk stratification of impairment of kidney function in cirrhosis. J Hepatol. 2013;59:474–81.

    Article  PubMed  Google Scholar 

  53. Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993;105:229–36.

    CAS  PubMed  Google Scholar 

  54. Ruiz-del-Arbol L, Monescillo A, Arocena C, et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology. 2005;42:439–47.

    Article  CAS  PubMed  Google Scholar 

  55. Tandon P, Garcia-Tsao G. Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol. 2011;9:260–5. Systematic review of the literature that underlines renal dysfunction as the main determinant of survival in patients with SBP, identifying a subpopulation of patients who should receive more aggressive therapies to prevent progression of AKI.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Hung TH, Tsai CC, Hsieh YH, Tseng CW, Tsai JJ. Effect of renal impairment on mortality of patients with cirrhosis and spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol. 2012;10:677–81.

    Article  PubMed  Google Scholar 

  57. Cho Y, Park SY, Lee JH, et al. High-sensitivity C-reactive Protein Level is an Independent Predictor of Poor Prognosis in Cirrhotic Patients With Spontaneous Bacterial Peritonitis. J Clin Gastroenterol 2013.

  58. Tandon P, Kumar D, Seo YS, et al. The 22/11 risk prediction model: a validated model for predicting 30-day mortality in patients with cirrhosis and spontaneous bacterial peritonitis. Am J Gastroenterol 2013;108:1473–9. This study evaluates combining MELD score and leukocytosis, designated the 22/11 risk score, in the prediction of 30 day mortality in patients with SBP. Main prognostic factors were a MELD ≥ 22 and peripheral leukocyte count ≥11,000/mm 3 . Patients who had none, one or both negative prognostic factors had a 30-day mortality of 8%, 32% and 52%, respectively.

  59. Reuken PA, Stallmach A, Bruns T. Mortality after urinary tract infections in patients with advanced cirrhosis - Relevance of acute kidney injury and comorbidities. Liver Int. 2013;33:220–30.

    Article  PubMed  Google Scholar 

  60. Romero-Gomez M, Grande L, Camacho I, Benitez S, Irles JA, Castro M. Altered response to oral glutamine challenge as prognostic factor for overt episodes in patients with minimal hepatic encephalopathy. J Hepatol. 2002;37:781–7.

    Article  CAS  PubMed  Google Scholar 

  61. Cordoba J, Ventura-Cots M, Simon-Talero M, et al. Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute-on-chronic liver failure (ACLF). J Hepatol 2013.

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Guadalupe Garcia-Tsao, Alexander Zipprich and Cristina Ripoll declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Medicine I, Martin-Luther-University Halle-Wittenberg, Halle, Germany

    Cristina Ripoll & Alexander Zipprich

  2. Digestive Diseases Section, Yale University School of Medicine, 333 Cedar Street – 1080 LMP, New Haven, CT, 06510, USA

    Guadalupe Garcia-Tsao

  3. VA-Connecticut Healthcare System, Digestive Diseases Section, 950 Campbell Ave, West Haven, CT, 06516, USA

    Guadalupe Garcia-Tsao

Authors
  1. Cristina Ripoll
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexander Zipprich
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Guadalupe Garcia-Tsao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Guadalupe Garcia-Tsao.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ripoll, C., Zipprich, A. & Garcia-Tsao, G. Prognostic Factors in Compensated and Decompensated Cirrhosis. Curr Hepatology Rep 13, 171–179 (2014). https://doi.org/10.1007/s11901-014-0234-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11901-014-0234-6

Keywords

Search

Navigation