EASL Studio S4E4 - JHEP Live: Is the term ‘decompensated cirrhosis’ outdated?

Name: EASL Studio S4E4 - JHEP Live: Is the term ‘decompensated cirrhosis’ outdated?
Uploaded: 2023-02-02T12:24:08.000Z
Duration: 1 h 12 min 25 s

Foreign Language

The video starts with foreign language music playing in the background.

Is Decompensated Cirrhosis Outdated?

In this section, the host introduces the topic of discussion and explains that they will be discussing whether the term "decompensated cirrhosis" is outdated. They also mention that they will be reflecting on this issue and trying to develop a path towards a global consensus on definition and terminology.

Definition of Decompensation

The authors have introduced new definitions of decompensation, including acute decompensation and further compensation.

The host asks the experts for their current idea of the definition of decompensation.

One expert believes that decompensation is not outdated and is a game-changing turning point in the natural history of cirrhosis.

Another expert agrees that decompensation is still very significant and should be clinically relevant in terms of prognosis or treatment.

A third expert also agrees that decompensated cirrhosis is not outdated and should be based on compensated and decompensated cirrhosis.

Criteria for Decompensation

Experts agree that decompensation should be a direct consequence of the disease, associated with worse prognosis, easy to diagnose, and meet certain criteria such as ascites, variceal bleeding, hepatic encephalopathy, or jaundice.

Jaundice is rare as a first episode but may qualify as a patient with further or acute decompensation.

Sarcopenia

The host asks if sarcopenia should be included in the definition of decompensation.

Experts agree that sarcopenia is an important factor to consider but may not meet all the criteria for decompensation.

Sarcopenia and Decompensation

The speakers discuss whether sarcopenia should be considered a defining factor for decompensation in cirrhosis.

Sarcopenia as a Decompensating Event

Albumin levels may correlate with sarcopenia, but it is not clearly related to cirrhosis per se.

Sarcopenia is more of an associated condition rather than a defining factor for decompensation.

It needs to be assessed when developing prognostic models, but it is not typical to include in the definition of decompensation.

Acute vs Non-Acute Decompensation

The speakers discuss the two different patterns of decompensation: acute and non-acute.

Defining Acute Decompensation

Bleeding is acute by definition, while encephalopathy could be chronic or acute depending on the patient's presentation.

Ascites can be based on the patient and provider's decision to hospitalize or not, making it difficult to define as acute.

There is no need to discriminate between acute and non-acute or progressive decompensation since all events can go from mild to severe.

Prognostic Factors for Decompensation

Within different types of prognostic decompensations, specific factors should be identified.

Multi-pathic encephalopathy can range from very transient to severe jaundice with bilirubin levels of 25 or higher.

Defining Acute Decompensation

In this section, the speakers discuss the need for a better definition of acute decompensation and how it can help in managing patients.

Hospitalization Criteria

The need for hospitalization depends on the healthcare system.

A potential weakness is how to define activity that requires hospitalization.

Better characterization of acuity according to pathophysiology and precipitating events can help define different pathways for patient management.

Prognosis and Prevention

The hypothesis makes sense if we prove that the prognosis in patients with acute compensation is different than in patients with non-acute compensation.

Doing something will prevent them from the same thing.

Acute decompensation identifies a cohort of patients that then develop acute on chronic liver failure with a very high mortality rate at 28 days.

Personalized Precision Medicine

In the era of personalized precision medicine, a better definition of pathophysiological background based on big data and omic data would be useful.

Predicting ACLS

In this section, the speakers discuss predicting ACLS and identifying patients who require hospitalization.

Identifying Patients

Only 30% really develop ACLS so criteria should be more strict to identify those who are going to go through it.

Clinical and other parameters would be useful to try to give us a higher percentage in identifying those who require hospitalization.

Severity Variation

In this section, the speakers discuss how each decompensation can vary in severity.

Decompensation Severity

Acute variceal bleeding must be admitted if this is not a limited setting.

Patients with very severe cirrhosis might go under paracentesis in an outpatient setting and are at risk for developing hepatorenal syndrome and later on ACLF.

Each decompensation can vary in their severity.

Definition of Acute Decompensation

In this section, the speakers discuss the definition of acute decompensation and its relationship to further decompensation.

Characteristics of Decompensated Cirrhosis

The characteristics of decompensated cirrhosis such as inflammation, sequestration dysfunction markers or portal hypertension are important for pathophysiology.

Acute decompensation occurs in one-third of cases as the first event in patients with compensated cirrhosis.

75% of patients who experience acute decompensation have had a previous decomposition event before.

Patients experiencing acute decompensation are much sicker and belong to a severe end of the spectrum.

Harmonizing Definitions

The majority of cases where acute compensation occurs should be considered under the umbrella of further decompensation.

Exceptions exist, but generally, when thinking about these patients, it is having not only complicated portal hypertension but also liver insufficiency and more inflammation that makes them sicker.

Importance of Acuity Events

In this section, the speakers discuss the importance of acuity events and their relationship to mortality rates.

Risk Factors for Mortality

Patients who develop their first decompensation as an acute decompensation are at increased risk for mortality.

Economic data highlights the importance of acuity events as a first sign for predicting mortality rates.

Bacterial Infections and Decompensated Cirrhosis

In this section, the speakers discuss whether bacterial infections should be included in the definition of acute compensation or further decompensation.

Bacterial Infections as Precipitating Events

Bacterial infections are mostly events that trigger decompensation and should be considered precipitating events.

Defining Decompensation and Recompensation

In this section, the speakers discuss their definition of decompensation and recompensation in cirrhosis patients.

Decompensation

Infections are considered a trigger for decompensation, not a direct consequence of the disease.

Patients with cirrhosis have immune dysfunction and increased intestinal permeability, making them more susceptible to infections.

Spontaneous bacterial peritonitis (SBP) is the only potential infection that can be considered as further decompensation because it is specific to cirrhosis.

Recompensation

Recompensation occurs when a patient returns to an entirely compensated stage after being decompensated due to treatment of etiology and resolution of liver synthetic function.

Removal of the etiology is crucial for recompensation, along with normal liver synthetic function and disappearance of ascites without diuretics.

Refining Criteria for Recompensation

In this section, the speakers discuss refining criteria for recompensation in cirrhosis patients.

The removal of ecological factors and improvement in synthetic function are key factors in defining recompensated patients.

The refinement of criteria will come when we are sure that patients will not have complications from varices or variceal hemorrhages.

Recompensated Cirrhosis: To Treat or Not to Treat

In this section, the experts discuss the use of beta-blockers for patients with recompensated cirrhosis and clinically significant portal hypertension (CSHP). They also talk about the decision-making process for withdrawing diuretics or warfarin.

Beta-Blockers for Patients with CSHP

Beta-blockers are effective for patients with recompensated cirrhosis who still suffer from CSHP.

The decision to withdraw beta-blockers is based on physician perspectives and patient response.

Patients who achieve a label of "recompensation" can have their beta-blocker treatment withdrawn.

Decision-Making Process for Withdrawing Diuretics or Warfarin

The decision to suspend or withdraw diuretics or warfarin is often based on physician perspectives.

Ultrasound screenings every six months can help determine if treatment withdrawal is appropriate.

Clear points need to be identified before confidently withdrawing treatment.

Planning an International Multi-Center Trial in Decompensated Cirrhosis

In this section, the experts discuss the need for a large perspective international multi-center trial in patients with decompensated cirrhosis. They also talk about how collaboration and data sharing can lead to a better understanding of compensated cirrhosis and patterns of decompensation.

Need for an International Multi-Center Trial

A large perspective international multi-center trial in patients with decompensated cirrhosis may be necessary to get a consensus on terminology and definitions.

Clear definitions of patient classification are necessary for the trial to be successful.

The trial would help further stratify patients with cirrhosis and improve understanding of patterns of decompensation.

Collaboration and Data Sharing

Collaboration and data sharing can lead to a better understanding of compensated cirrhosis and patterns of decompensation.

Baveno and U.S. centers will participate in the study.

The next episode will cover the basics of artificial intelligence in hepatology.

Conclusion

In this section, the experts conclude the session and thank attendees for their participation.

Attendees are thanked for their participation.

The session ends.