Clinical Evaluation and Prognosis

Abstract

Background: Liver cirrhosis is no longer considered a homogeneous disease, with two different phases now identified: ‘compensated' and ‘decompensated' cirrhosis, in which complications of cirrhosis characterize the latter. Within each phase, different stages and predictors should be recognized in order to correctly stratify the prognosis and individualize possible therapeutic options. Key Messages: In compensated cirrhosis the presence of clinically significant portal hypertension [CSPH = hepatic venous pressure gradient (HVPG) ≥10 mm Hg] constitutes the most important independent predictor of several relevant clinical endpoints (formation of esophageal varices; first clinical decompensation). An optimal HVPG response to medical therapy of portal hypertension (HVPG reduction <12 mm Hg or ≥20% vs. the pretreatment value, responders) has been consistently linked to a decrease in the risk of variceal bleeding both in primary and secondary prophylaxis, and to a decrease in the risk of presenting other clinical decompensating events. Furthermore, in patients undergoing secondary prophylaxis of variceal bleeding, being an HVPG responder is associated with an improved survival. HVPG also maintains an independent prognostic value in patients with decompensated cirrhosis. Noninvasive alternatives to HVPG for the prediction of CSPH have been investigated; liver stiffness by transient elastography and the combination of liver stiffness, spleen size by ultrasound and platelet count are currently the best methods to noninvasively diagnose CSPH, with an accuracy of about 90%. Additional factors modulate prognosis in cirrhosis. Liver function (albumin, bilirubin, INR) is independently associated with prognosis both in compensated and decompensated cirrhosis, and in the latter phase renal function also plays a central role. Among clinical cofactors, obesity and diabetes are emerging as variables increasing the risk of progression to decompensation and death in cirrhosis. Conclusions: Prognostic stratification in patients with cirrhosis should take into account a complex interplay of several clinical, hemodynamic and biological variables. The present review summarizes the existing evidence regarding prognostic factors in cirrhosis, with particular emphasis on compensated cirrhosis.