Refining Prognosis in Cirrhosis Patients With Ascites: Impact of Acute vs. Non-Acute Decompensation

Background: A more granular understanding of hepatic decompensation in cirrhosis has led to the classification of acute decompensation (AD) and non-acute decompensation (NAD). In this study, we assessed differences in the clinical course of AD versus NAD in patients with ascites as the first decompensation event. Methods: 505 cirrhosis patients with ascites as first decompensation were included in this single-center longitudinal cohort study and followed until further decompensation, orthotopic liver transplantation (OLT), or death. AD was defined as grade 3 ascites or ascites with spontaneous bacterial peritonitis (SBP) or acute-kidney injury (AKI), while NAD was defined as grade 2 ascites. Hospitalisation was recorded. Results: Among 505 patients, 296 (58.6%) met the criteria for AD, with 216 (73.0%) requiring hospitalisation. NAD occurred in 209 (41.4%), with 107 (51.2%) requiring hospitalisation. During a median 4.4-year follow-up, further decompensation occurred in 65.1%, acute-on-chronic liver failure (ACLF) in 27.7%, 10.9% underwent OLT, and 51.1% died. Patients with AD had a higher incidence of further decompensation (at 12 months: 19% and 33%) and a higher risk of transplant-free mortality (subdistribution hazard ratio [SHR]: 1.43 [95% CI: 1.12–1.82], p = 0.004) versus NAD. When stratified by hospitalisation, AD was associated with an increased risk of mortality only in cases requiring hospitalisation (SHR for hospitalised AD vs. non-hospitalised NAD: 1.89, 95% CI: 1.35–2.65, p < 0.001). Inflammation (C-reactive protein) predicted transplant-free mortality in AD (SHR per log-change: 1.20 [95% CI: 1.02–1.41], p = 0.032) but not NAD. Conclusions: Classifying patients as AD versus NAD identified subgroups with different risks for further decompensation and transplant-free mortality.