PROGRESSIVE ALTERATIONS IN SYSTEMIC AND CARDIOPULMONARY HEMODYNAMICS OCCUR IN PATIENTS WITH CIRRHOSIS AND PREDICT DEATH IN DECOMPENSATED CIRRHOSIS

Background and Aims: The main stages of cirrhosis (compensated and decompensated) have been substaged based on clinical, endoscopic, and portal pressure (determined by the hepatic venous pressure gradient, HVPG) features. Vasodilation leading to a hyperdynamic circulatory state is central in the development of a late decompensated stage with inflammation being currently considered a key driver. We aimed to assess hepatic/systemic hemodynamics and inflammation (by C reactive protein, CRP) among the different substages of cirrhosis and to investigate their interrelationship and prognostic relevance.
Methods: Single center, prospective cohort of patients with cirrhosis undergoing per protocol hepatic and right-heart catheterization and CRP measurement, classified into recently defined prognostic stages (PS) of compensated (PS1: HVPG ≥6mmHg but <10mmHg; PS2: HVPG ≥10 mmHg without gastroesophageal varices; PS3: patients with gastroesophageal varices) and decompensated (PS4: diuretic-responsive ascites; PS5: refractory ascites) disease. Cardiodynamic states based on cardiac index (L/min/m2) were created: relatively-hypodynamic (<3.2), normodynamic (3.2-4.2) and hyperdynamic (>4.2).
Results: 238 patients, 151 compensated (PS1=25; PS2=36; PS3=90), 87 decompensated (PS4=48; PS5=39). Mean arterial pressure decreased progressively from PS1 to PS5, cardiac index increased progressively from PS1-to-PS4 but decreased in PS5. HVPG, MELD, and CRP increased progressively from PS1-to-PS5. Among compensated patients, age, HVPG, relatively-hypodynamic/hyperdynamic state and CRP were predictive of decompensation. Among patients with ascites, MELD, relatively-hypodynamic/hyperdynamic state, post-capillary pulmonary hypertension, and CRP were independent predictors of death/liver transplant.
Conclusions: Our study demonstrates that, in addition to known parameters, cardiopulmonary hemodynamics and CRP are predictive of relevant outcomes in patients with both compensated and decompensated cirrhosis.