Click on the blue word. **
Cirrhosis is not a separate disease, but a common outcome of multiple chronic liver diseases progressing to an advanced stage. It is estimated that more than 1 million people die from cirrhosis each year worldwide, and it is the leading cause of death from various chronic liver diseases. Worldwide, the age-standardized mortality rate for cirrhosis decreases, but the number of deaths from cirrhosis continues to increase due to the increase in the total population and changes in population composition.
Professor Jia Jidong from Beijing Friendship Hospital affiliated to Capital Medical UniversityThe academic report on "Research Progress on Decompensation and Recompensation of Liver Cirrhosis" was shared, and the essence is now compiled into a text for readers.
1. Changes in liver cirrhosis
Cirrhosis is a liver disease that causes liver damage caused by various reasons, resulting in liver fibrosis and changes in the structure of liver lobules, and then develops to an advanced stage. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, alcoholic liver disease, and non-alcoholic (metabolic-related) fatty liver disease (NAFLD MAFLD) are the leading causes of chronic liver diseases (including cirrhosis and liver cancer) worldwide**.
Patients with cirrhosis** in different parts of the world are different, the Asia-Pacific region is dominated by HBV infection except Japan, Europe is dominated by alcoholic liver disease and HCV infection, the United States is mainly HCV infection and alcoholic liver disease, and the cirrhosis and liver cancer caused by NAFLD MAFLD are increasing year by year worldwide.
Due to the increase in global population size and demographic changes, age-standardized cirrhosis mortality decreased from 1990 to 2017, but the number of deaths from cirrhosis continued to rise globally. From 1990 to 2017, the number of patients with cirrhosis caused by HBV infection and HCV infection will decrease, while the number of patients with cirrhosis caused by alcoholic liver disease and NAFLD MAFLD will gradually increase. From 1990 to 2016, the age of patients dying from liver cirrhosis in China was concentrated in 50-60 years, and HBV infection was the main disease [1]. The prevalence of NAFLD in the Asia-Pacific region is also increasing year by year [2].
2. Staging changes of liver cirrhosis
Cirrhosis is not an independent disease, any chronic liver disease can lead to liver fibrosis after repeated and persistent liver damage, and once accompanied by changes in the structure of the liver lobules, cirrhosis is formed, which is mainly manifested by hepatocellular dysfunction and portal hypertension. Initially, cirrhosis is divided into compensated and decompensated phases. Compensated cirrhosis refers to patients who have not yet developed serious complications such as ascites, esophageal and gastric variceal bleeding, and hepatic encephalopathy; Once one of the above complications occurs, decompensated cirrhosis is diagnosed.
Subsequently, a stage 5 classification of cirrhosis was proposed internationally [3]. Stage 1 is no esophagogastric varices and ascites, stage 2 is esophagogastric varices but no ascites, stage 3 is ascites with no esophagogastric varices, stage 4 is bleeding with esophageal varices with no ascites, and stage 5 is sepsis. The advantage of this staging is that it is related to case fatality rate. With the aggravation of staging, the case fatality rate gradually increases, which is conducive to clinical judgment of patient prognosis.
Recently, a new stage 5 cirrhosis has been proposed in Europe and the United States based on HCV infection and alcoholic liver disease as the main cirrhosis[4]
Stage 1 is compensated cirrhosis without esophagogastric varices;
Stage 2 is compensated cirrhosis with esophagogastric varices;
Stage 3 is only esophageal variceal bleeding;
Stage 4 is the first occurrence of a decompensation event other than bleeding;
Stage 5 is the occurrence of two decompensated events.
The 1-year case fatality rate gradually increased in each stage, to about % and 88%, respectively. Whether this stage is suitable for the Asia-Pacific region, where HBV infection is predominant, is still up for debate.
All in all, once a patient progresses to the decompensated stage, the mortality rate increases substantially. In addition, the prognosis of cirrhosis due to nonalcoholic steatohepatitis (NASH) is worse than cirrhosis due to HBV infection [5]. Patients with cirrhosis caused by NASH have a higher incidence of refractory ascites and hepatorenal syndrome, and a lower 1-year survival rate and 5-year survival rate. Clinically, more attention should be paid to NASH-related cirrhosis.
3. Definition and standard of recompensation for liver cirrhosis
For compensated cirrhosis, the main ones are *** such as antiviral for HBV and HCV**, and lifestyle changes include abstinence from alcohol, weight loss, diabetes, increased exercise, etc. **The aim is to prevent decompensation of cirrhosis and to reverse early cirrhosis. The principle of decompensated cirrhosis, in addition to continuing to carry out, should also prevent and prevent complications, such as ascites, esophageal varices, and hepatic encephalopathy. In particular, a meta-analysis by our team showed that it reduced the incidence of decompensated events and liver cancer [6].
In recent years, with the progress of the world, not only liver fibrosis or compensated cirrhosis can be reversed, but also the clinical manifestations of many patients with decompensated cirrhosis can also be reversed, that is, ascites, esophagogastric variceal bleeding or hepatic encephalopathy will no longer occur, which is called "recompensated phase".
A Korean study [7] analyzed the factors of hepatitis B decompensation and cirrhosis recompensation, and found 6 independent factors: bilirubin level 5 mg DL, no serious complications, AFP level 50 ng ml, ALT level 200 IU L, and international normalized ratio 15 and initiation of antiviral ** within 6 months after the first decompensation**, which can be used for **recompensation, and a prognostic model of BC2AID score was established.
Our team's study [8] showed that once recompensation was achieved, the 3-year mortality rate and liver transplantation rate were 29%, and the incidence of liver cancer was 126%；If recompensation is not achieved, the 3-year mortality rate and liver transplantation rate are 273%, and the incidence of liver cancer was 377%。
The B**Eno VII consensus published in 2022 [9] clearly defines cirrhosis recompensation for the first time:
1) removal of major inhibition of cirrhosis (eg, HCV clearance, sustained HBV inhibition, sustained alcohol abstinence due to alcoholic cirrhosis);
2) Ascites (discontinuation of diuretics) and hepatic encephalopathy (discontinuation of lactulose rifaximin) resolved, and there was no variceal bleeding for at least 12 months;
3) Liver function tests [albumin, international normalized ratio (INR), bilirubin] were steadily improved.
However, the definition of stable improvement in the above definition is not clearly defined. In order to address this important clinical question, Professor Xie Wen's team published a prospective cohort study in the Journal of Hepatology [10], enrolling a total of 320 patients with decompensated ascites in hepatitis B cirrhosis who received entecavir antiviral**.
Of the 283 patients who completed 120 weeks of follow-up observation, 60Four percent (171 283) of patients achieved recompensation as defined by the B**ENOVII consensus, i.e., resolution of ascites, relapse of hepatic encephalopathy, and absence of esophagogastric variceal bleeding for >12 months.
More importantly, this study further clarified the criteria for determining the stable improvement in liver function required to achieve recompensation: end-stage liver disease model (MELD) score < 10 points and or liver function index return to Child-Pugh grade A liver function level (albumin 35 g L, INR < 1.).50 and total bilirubin <34 mol l). According to this standard, 56Two percent (159 283) of patients fully met the definition of cirrhosis recompensation in the B**Eno VII consensus.
4. Comprehensive support for liver cirrhosis
Cirrhosis of the liver not only requires lifestyle improvements, including abstinence from alcohol, reasonable diet, oral hygiene, physical exercise, smoking cessation, etc. Patients with advanced decompensated cirrhosis can be given palliative care and symptomatic care, but not to give up the effective**, but to actively support the physiological, psychological and social needs of the patients while actively improving the quality of life and the survival rate.
The Clinical Practice Evaluation Committee of the American Society of Hepatology proposed 26 process indicators, 7 outcome indicators, and 13 patient-reported outcomes for the medical quality of liver cirrhosis to measure the standardization of diagnosis and treatment of liver cirrhosis. In short, in order to achieve the process in place, the outcome is good, and the patient is satisfied, it is necessary to return to the multidisciplinary diagnosis and treatment model, return to common sense, return to the classics, return to the clinic, and return to the humanities.
References Swipe up and down to view.
1. lim, et al. biomed environ sci 2020;33:1-10.
2. wong mcs, et al. nat rev gastroenterol hepatol 2019:16:57-73.
3. muir aj. clinical therapeutics 2015.
4. d'amico ggarcia-tsao g, et al. hepatology. 2020; 72:1029-42.
5. tan hk. et al. am jgastroenterol. 2021:116:1437-46.
6. kong y, et al. hepatol int 2022;16:1052-63.
7. kim th, et al. aliment pharmacol ther. 2022; 55:83-96.
8. he z, et al. scand j gastroenterol. 2022;1-9.
9. de franchis r et al. j hepatol. 2022;76(4):959-974.
10. wang q,et al. j hepatol. 2022: s0168-8278(22)03019-7.
Expert Profile
Professor Jia Jidong
Professor and Chief Physician of the Liver Disease Center of Beijing Friendship Hospital Affiliated to Capital Medical University.
Director of the Diagnosis and Treatment and Research Center for Liver Cirrhosis and Portal Hypertension, Capital Medical University.
Chairman of the Hepatology Professional Committee of the Gastroenterologist Branch of the Chinese Medical Doctor Association.
Chairman of the Hepatology Branch of the Chinese Medical Association (2006-2012).
President of the Asia-Pacific Society of Hepatology (APASL 2009 2010).
President of the International Society of Hepatology (IASL 2013-2016).
Vice Chairman of the Chinese Association for Hepatitis Prevention and Control (2010-2020).
He has successively served as the associate editor and co-editor-in-chief of domestic and foreign journals such as Hepatol Int, Liver Int, JGH, JCTH, Chinese Journal of Hepatology, Journal of Clinical Hepatobiliary Diseases and Liver.
Organized by Professor Jia Jidong
Disclaimer: This article is only for medical and health professionals to understand the latest medical information, and does not represent the views of this platform. This information is not intended to be a substitute for professional medical guidance in any way, nor should it be construed as medical advice, and neither the site nor the author shall be liable if the information is used for purposes other than information.
*: Hepatobiliary photographic platform.