Dr Bosch: It is time to abandon this term, because, apart from having negative connotations, there is the problem that the term was firstly a specific anatomical diagnosis which requires an invasive liver biopsy for confirmation and refers to an anatomical finding that can coincide with several stages of the disease. So, by itself, the term has very little prognostic significance because the prognosis for cirrhosis is very different in the compensated versus decompensated stages. Biopsy will not tell you if the condition is compensated or decompensated, so it has very little prognostic significance and is not practical in terms of assessing disease, also because it cannot be repeated frequently. It is anecdotal to have this histological diagnosis in many cases, so it is better to refer to the disease as a continuum and qualify the different stages according to each stage’s prognosis and patient characteristics.

 

Dr Bosch: Compensated advanced chronic liver disease (ACLD) can persist for many years without a lot of discomfort for the patient, and usually totally asymptomatic. When we have a patient in this stage, what we want is to prevent decompensation, which is when the disease becomes more severe with a high mortality. We know a patient decompensates when they develop complications from portal hypertension. The first thing we do with a compensated patient is to assess if they have portal hypertension, as that determines the degree of risk of decompensating. Having no portal hypertension does not require a lot of treatment effort. If the patient already has portal hypertension, a closer look is required as the risk for decompensating is around 10% per year.

 

Dr Bosch: Progress has been enormous. When we compare the prognosis of the complications of cirrhosis, like variceal bleeding, for instance, just thirty years ago, it was 40-50% mortality per episode, whereas nowadays, it is <15%. The same has happened with other complications of cirrhosis. Even though cirrhosis is a very severe disease when it decompensates, we have good treatments for these patients that prevent them dying from those complications. We can significantly prolong their life expectancy. In cases of decompensated cirrhosis, we need to first treat the acute decompensation event, and then prevent further decompensation. For this we have different stages of medical therapy, which can be optimized for patients with the most severe liver disease with the option for liver transplantation, the only definitive cure for the disease. So the prognosis for these patients has changed markedly over the last thirty years, with things much better than they were. We have hope for these patients today that was not present before. And this is continuing to improve. The prognosis for decompensated cirrhotics is likely to be even better in a few years time with new treatments and strategies for these patients.