Predictors of clinical trajectories in patients admitted for acutely decompensated cirrhosis: An external validation of the PREDICT study

Introduction The PREDICT study has recently shown that acutely decompensated (AD) cirrhotic patients without acute-on-chronic liver failure (ACLF) present three different clinical trajectories and mortality rates: pre-ACLF, developing ACLF within 90 days; Unstable Decompensated Cirrhosis (UDC), who were readmitted within 90-days or die without ACLF; and Stable Decompensated Cirrhosis (SDC), without ACLF or readmissions. Aims This study aimed to i) validate the existence of three distinct trajectories in AD patients, and ii) identify predictors for the occurrence of each trajectory. Methods Baseline data, 3-months ACLF and readmission incidence, and 1-year survival were analyzed in a prospective cohort of patients admitted for AD. A pre-specified multinomial multivariable model (MNM) was used to evaluate the association between baseline features and the clinical trajectories. Results Of the 311 patients enrolled, 169 (55%) met the criteria for SDC, 57 (18%) for UDC, and 85 (27%) for pre-ACLF. The 1-year mortality was significantly different between the three groups: pre-ACLF 65%, UDC 46% and SDC 21% (p<0.001). Marginal changes of the probability of pre-ACLF, SDC and UDC attributable to the predictors are reported in Figure 1. Among clinical parameters, the presence of hepatic encephalopathy was associated to UDC (p=0.043), while the absence of ascites to SDC (p=0.017). Among lab parameters, an increase of MELD-Na (p=0.000) and C-Reactive Protein (p=0.009) and a decrease of hemoglobin (p=0.004) and albumin (p=0.008) levels were associated to pre-ACLF. Conclusion The present study confirms that patients with AD have 3 different clinical trajectories associated to different mortality rates. Besides severity of cirrhosis, the association with CRP supports the predominant role of systemic inflammation in ACLF pathophysiology. Moreover, low hemoglobin levels also predict ACLF within 90 days. Finally, HE is associated to the UDC trajectory highlighting the need of a better management of this complication after discharge.