Skip to main content
SpringerLink
Log in

Predictors of Clinical Complications of Cirrhosis

  • Chapter
  • First Online:
Complications of Cirrhosis

  • 2025 Accesses

Abstract

Liver disease is a common problem in the USA and its end histologic stage is cirrhosis. Individuals with cirrhosis can have catastrophic clinical complications. Timely intervention can limit the impact of these complications, which makes recognition and prognostication paramount in the management of cirrhosis. Furthermore, the ultimate cure of decompensated cirrhosis is liver transplant, which requires demonstration of urgency using prognostic modeling for priority. This chapter outlines the clinical complications of cirrhosis, their prognoses, and prognostic tools to stratify severity of patients with cirrhosis.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. US Burden of Disease Collaborators. The state of US health, 1999–2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591–608.

    Article  Google Scholar 

  2. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44(1):217–31.

    Article  PubMed  Google Scholar 

  3. Gines P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology. 1987;7(1):122–8.

    Article  CAS  PubMed  Google Scholar 

  4. Gines P, Fernandez-Esparrach G, Arroyo V. Ascites and renal functional abnormalities in cirrhosis. Pathogenesis and treatment. Bailliere’s Clin Gastroenterol. 1997;11(2):365–85.

    Article  CAS  Google Scholar 

  5. Gines P, Cardenas A, Arroyo V, Rodes J. Management of cirrhosis and ascites. New Engl J Med. 2004;350(16):1646–54.

    Article  CAS  PubMed  Google Scholar 

  6. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut. 2006;55(Suppl 6):vi1–12.

    PubMed Central  PubMed  Google Scholar 

  7. Somsouk M, Kornfield R, Vittinghoff E, Inadomi JM, Biggins SW. Moderate ascites identifies patients with low model for end-stage liver disease scores awaiting liver transplantation who have a high mortality risk. Liver Transpl. 2011;17(2):129–36.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Runyon BA. Bacterial infections in patients with cirrhosis. J Hepatol. 1993;18(3):271–72.

    Article  CAS  PubMed  Google Scholar 

  9. Laffi G, Carloni V, Baldi E, et al. Impaired superoxide anion, platelet-activating factor, and leukotriene B4 synthesis by neutrophils in cirrhosis. Gastroenterology. 1993;105(1):170–7.

    CAS  PubMed  Google Scholar 

  10. Tritto G, Frances R, Shah N, et al. Plasma from stable patients with cirrhosis transmits severe neutrophil phagocytic dysfunction which is independent of the presence of bacterial DNA and associated with increased expression of TLR-4. Hepatology. 2009;50:311A.

    Google Scholar 

  11. Bauer TM, Steinbruckner B, Brinkmann FE, et al. Small intestinal bacterial overgrowth in patients with cirrhosis: prevalence and relation with spontaneous bacterial peritonitis. Am J Gastroenterol. 2001;96(10):2962–7.

    Article  CAS  PubMed  Google Scholar 

  12. Scarpellini E, Valenza V, Gabrielli M, et al. Intestinal permeability in cirrhotic patients with and without spontaneous bacterial peritonitis: is the ring closed? Am J Gastroenterol. 2010;105(2):323–27.

    Article  PubMed  Google Scholar 

  13. Cirera I, Bauer TM, Navasa M, et al. Bacterial translocation of enteric organisms in patients with cirrhosis. J Hepatol. 2001;34(1):32–7.

    Article  CAS  PubMed  Google Scholar 

  14. Grace ND. Prevention of initial variceal hemorrhage. Gastroenterol Clin N Am. 1992;21(1):149–61.

    CAS  Google Scholar 

  15. D’Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38(3):599–612.

    Article  PubMed  Google Scholar 

  16. Gines P, Schrier RW. Renal failure in cirrhosis. N Engl J Med. 2009;361(13):1279–90.

    Article  CAS  PubMed  Google Scholar 

  17. Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56(9):1310–8.

    PubMed Central  CAS  PubMed  Google Scholar 

  18. Gines A, Escorsell A, Gines P, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology. 1993;105(1):229–36.

    CAS  PubMed  Google Scholar 

  19. Cardenas A, Kelleher T, Chopra S. Review article: hepatic hydrothorax. Aliment Pharmacol Ther. 2004;20(3):271–9.

    Article  CAS  PubMed  Google Scholar 

  20. Porcel JM. Management of refractory hepatic hydrothorax. Curr Opin Pulm Med. 2014;20(4):352–7.

    Article  PubMed  Google Scholar 

  21. Xiol X, Castellvi JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719–23.

    Article  CAS  PubMed  Google Scholar 

  22. Benjaminov FS, Prentice M, Sniderman KW, Siu S, Liu P, Wong F. Portopulmonary hypertension in decompensated cirrhosis with refractory ascites. Gut. 2003;52(9):1355–62.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Robalino BD, Moodie DS. Association between primary pulmonary hypertension and portal hypertension: analysis of its pathophysiology and clinical, laboratory and hemodynamic manifestations. J Am Coll Cardiol. 1991;17(2):492–8.

    Article  CAS  PubMed  Google Scholar 

  24. Colle IO, Moreau R, Godinho E, et al. Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study. Hepatology. 2003;37(2):401–9.

    Article  PubMed  Google Scholar 

  25. Deng Z, Haghighi F, Helleby L, et al. Fine mapping of PPH1, a gene for familial primary pulmonary hypertension, to a 3-cM region on chromosome 2q33. Am J Respir Crit Care Med. 2000; 161(3 Pt 1):1055–9.

    Article  CAS  PubMed  Google Scholar 

  26. Lebrec D, Capron JP, Dhumeaux D, Benhamou JP. Pulmonary hypertension complicating portal hypertension. Am Rev Respir Dis. 1979;120(4):849–56.

    CAS  PubMed  Google Scholar 

  27. Panos RJ, Baker SK. Mediators, cytokines, and growth factors in liver-lung interactions. Clin Chest Med. 1996;17(1):151–69.

    Article  CAS  PubMed  Google Scholar 

  28. Hoeper MM, Krowka MJ, Strassburg CP. Portopulmonary hypertension and hepatopulmonary syndrome. Lancet. 2004;363(9419):1461–8.

    Article  PubMed  Google Scholar 

  29. Krowka MJ, Cortese DA. Hepatopulmonary syndrome: an evolving perspective in the era of liver transplantation. Hepatology. 1990;11(1):138–42.

    Article  CAS  PubMed  Google Scholar 

  30. Schenk P, Schoniger-Hekele M, Fuhrmann V, Madl C, Silberhumer G, Muller C. Prognostic significance of the hepatopulmonary syndrome in patients with cirrhosis. Gastroenterology. 2003;125(4):1042–52.

    Article  PubMed  Google Scholar 

  31. Goldberg DS, Krok K, Batra S, Trotter JF, Kawut SM, Fallon MB. Impact of the hepatopulmonary syndrome MELD exception policy on outcomes of patients after liver transplantation: an analysis of the UNOS database. Gastroenterology. 2014;146(5):1256–65.e1251.

    Article  PubMed  Google Scholar 

  32. Romero-Gomez M, Boza F, Garcia-Valdecasas MS, Garcia E, Aguilar-Reina J. Subclinical hepatic encephalopathy predicts the development of overt hepatic encephalopathy. Am J Gastroenterol. 2001;96(9):2718–23.

    Article  CAS  PubMed  Google Scholar 

  33. Sharma P. Minimal hepatic encephalopathy. J Assoc Physicians India. 2009;57:760–3.

    PubMed  Google Scholar 

  34. Bustamante J, Rimola A, Ventura PJ, et al. Prognostic significance of hepatic encephalopathy in patients with cirrhosis. J Hepatol. 1999;30(5):890–5.

    Article  CAS  PubMed  Google Scholar 

  35. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006;45(4):529–38.

    Article  PubMed  Google Scholar 

  36. Caldwell SH, Crespo DM, Kang HS, Al-Osaimi AM. Obesity and hepatocellular carcinoma. Gastroenterology. 2004; 127(5 Suppl 1):S97–103.

    Article  CAS  PubMed  Google Scholar 

  37. Dyson J, Jaques B, Chattopadyhay D, et al. Hepatocellular Cancer—the impact of obesity, type 2 diabetes and a multidisciplinary team. J Hepatol. 2014;60(1):110–17.

    Google Scholar 

  38. Altekruse SF, McGlynn KA, Reichman ME. Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol. 2009;27(9):1485–91.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Montano-Loza AJ, Meza-Junco J, Prado CM, et al. Muscle wasting is associated with mortality in patients with cirrhosis. Clin Gastroenterol Hepatol. 2012;10(2):166–73, e161.

    Article  PubMed  Google Scholar 

  40. Dasarathy S. Consilience in sarcopenia of cirrhosis. J Cachexia Sarcopenia Muscle. 2012;3(4):225–37.

    Article  PubMed Central  PubMed  Google Scholar 

  41. Kalaitzakis E, Josefsson A, Castedal M, et al. Factors related to fatigue in patients with cirrhosis before and after liver transplantation. Clin Gastroenterol Hepatol. 2012;10(2):174–81, e171.

    Article  PubMed  Google Scholar 

  42. Child CG, Turcotte JG. Surgery and portal hypertension. In: Child CG, editor. The liver and portal hypertension. Philadelphia: Saunders; 1964:p. 50–64.

    Google Scholar 

  43. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973 Aug;60(8):646–9.

    Article  CAS  PubMed  Google Scholar 

  44. Christensen E, Schlichting P, Fauerholdt L, et al. Prognostic value of Child-Turcotte criteria in medically treated cirrhosis. Hepatology. 1984;4(3):430–5.

    Article  CAS  PubMed  Google Scholar 

  45. Biggins SW, Bambha K. MELD-based liver allocation: who is underserved? Semin Liver Dis. 2006;26(3):211–20.

    Article  PubMed  Google Scholar 

  46. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864–71.

    Article  CAS  PubMed  Google Scholar 

  47. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2):464–70.

    Article  CAS  PubMed  Google Scholar 

  48. Wiesner R, Edwards E, Freeman R, et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91–6.

    Article  PubMed  Google Scholar 

  49. Wedd JP, Harper AM, Biggins SW. MELD score, allocation, and distribution in the United States. Clin Liver Dis. 2013; 2(4):148–51.

    Article  Google Scholar 

  50. Boleslawski E, Petrovai G, Truant S, et al. Hepatic venous pressure gradient in the assessment of portal hypertension before liver resection in patients with cirrhosis. Br J Surg. 2012;99(6):855–63.

    Article  CAS  PubMed  Google Scholar 

  51. Forner A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis. 2010;30(1):61–74.

    Article  CAS  PubMed  Google Scholar 

  52. Edge SB, Byrd DR, Compton CC, et al. AJCC cancer staging manual. 7th ed. New York:Springer; 2010.

    Google Scholar 

  53. Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996;334(11):693–9.

    Article  CAS  PubMed  Google Scholar 

  54. Yao FY, Ferrell L, Bass NM, et al. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology. 2001;33(6):1394–403.

    Article  CAS  PubMed  Google Scholar 

  55. Yao FY, Xiao L, Bass NM, Kerlan R, Ascher NL, Roberts JP. Liver transplantation for hepatocellular carcinoma: validation of the UCSF-expanded criteria based on preoperative imaging. Am J Transplant. 2007;7(11):2587–96.

    Article  CAS  PubMed  Google Scholar 

  56. Silva M, Moya A, Berenguer M, et al. Expanded criteria for liver transplantation in patients with cirrhosis and hepatocellular carcinoma. Liver Transplant. 2008;14(10):1449–60.

    Article  Google Scholar 

  57. Mazzaferro V, Llovet JM, Miceli R, et al. Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. Lancet Oncol. 2009;10(1):35–43.

    Article  PubMed  Google Scholar 

  58. Heuman DM, Abou-Assi SG, Habib A, et al. Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology. 2004;40(4):802–10.

    Article  PubMed  Google Scholar 

  59. Kim WR, Biggins SW, Kremers WK, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008;359(10):1018–26.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  60. Biggins SW, Kim WR, Terrault NA, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology. 2006;130(6):1652–60.

    Article  PubMed  Google Scholar 

  61. Bernardi M, Gitto S, Biselli M. The MELD score in patients awaiting liver transplant: strengths and weaknesses. J Hepatol. 2011;54(6):1297–306.

    Article  PubMed  Google Scholar 

  62. Barber K, Madden S, Allen J, Collett D, Neuberger J, Gimson A. Elective liver transplant list mortality: development of a United Kingdom end-stage liver disease score. Transplantation. 2011;92(4):469–76.

    Article  PubMed  Google Scholar 

  63. Heuman DM, Mihas AA, Habib A, et al. MELD-XI: a rational approach to “sickest first” liver transplantation in cirrhotic patients requiring anticoagulant therapy. Liver Transpl. 2007;13(1):30–7.

    Article  PubMed  Google Scholar 

  64. Bruix J, Gores GJ, Mazzaferro V. Hepatocellular carcinoma: clinical frontiers and perspectives. Gut. 2014:63(5);844–55.

    Google Scholar 

  65. Washburn K, Edwards E, Harper A, Freeman R. Hepatocellular carcinoma patients are advantaged in the current liver transplant allocation system. Am J Transplant. 2010;10(7):1643–48.

    Article  CAS  PubMed  Google Scholar 

  66. Toso C, Dupuis-Lozeron E, Majno P, et al. A model for dropout assessment of candidates with or without hepatocellular carcinoma on a common liver transplant waiting list. Hepatology. 2012;56(1):149–56.

    Article  PubMed  Google Scholar 

  67. Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144(7):1426–37, e1421–1429.

    Article  PubMed  Google Scholar 

  68. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  PubMed  Google Scholar 

  69. Jepsen P, Vilstrup H, Andersen PK, Lash TL, Sorensen HT. Comorbidity and survival of Danish cirrhosis patients: a nationwide population-based cohort study. Hepatology. 2008;48(1):214–20.

    Article  PubMed  Google Scholar 

  70. Volk ML, Hernandez JC, Lok AS, Marrero JA. Modified Charlson comorbidity index for predicting survival after liver transplantation. Liver Transpl. 2007 Nov;13(11):1515–20.

    Article  PubMed  Google Scholar 

  71. Jepsen P, Vilstrup H, Lash TL. Development and validation of a comorbidity scoring system for patients with cirrhosis. Gastroenterology. 2014 Jan;146(1):147–56; quiz e115–46.

    Article  PubMed  Google Scholar 

  72. Bittner V, Weiner DH, Yusuf S, et al. Prediction of mortality and morbidity with a 6-minute walk test in patients with left ventricular dysfunction. SOLVD Investigators. JAMA. 1993;270(14):1702–07.

    Article  CAS  PubMed  Google Scholar 

  73. Miyamoto S, Nagaya N, Satoh T, et al. Clinical correlates and prognostic significance of six-minute walk test in patients with primary pulmonary hypertension. Comparison with cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2000; 161(2 Pt 1):487–92.

    Article  CAS  PubMed  Google Scholar 

  74. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166:111–7.

    Article  Google Scholar 

  75. Carey EJ, Steidley DE, Aqel BA, et al. Six-minute walk distance predicts mortality in liver transplant candidates. Liver Transpl. 2010;16(12):1373–8.

    Article  PubMed  Google Scholar 

  76. Flegal KM, Graubard BI. Estimates of excess deaths associated with body mass index and other anthropometric variables. Am J Clin Nutr. 2009;89(4):1213–9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

Download references

Acknowledgment

This work was funded in part by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (DK076565) and from Agency for Healthcare Research and Quality (DK076565) to S.W.B. and from the National Institute of Health (5T32DK07038) to J.P.W.

Author information

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, University of Colorado Denver Division of Gastroenterology and Hepatology, Anschutz Outpatient Pavilion 7th Floor, 1635 Aurora Ct Mail Stop B-154, 80045, Aurora, CO, USA

    Scott W. Biggins MD, MAS

  2. Division of Digestive Diseases, Emory University Hepatology and Liver Transplantation, 1365 Clifton Rd NE Bld B, 6th Floor, Suite 6100, 30322, Atlanta, GA, USA

    Joel P Wedd MD, MPH

  3. University of Colorado Denver Department of Medicine, Aurora, CO, USA

    Avash Kalra MD

Authors
  1. Joel P Wedd MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Avash Kalra MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Scott W. Biggins MD, MAS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Scott W. Biggins MD, MAS .

Editor information

Editors and Affiliations

  1. Department of Transplant, Mayo Clinic, Jacksonville, Florida, USA

    Andrew P. Keaveny

  2. Institut de Malalties Digestives i Metaboliques, University of Barcelona, Barcelona, Spain

    Andrés Cárdenas

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Wedd, J., Kalra, A., Biggins, S. (2015). Predictors of Clinical Complications of Cirrhosis. In: Keaveny, A., Cárdenas, A. (eds) Complications of Cirrhosis. Springer, Cham. https://doi.org/10.1007/978-3-319-13614-1_4

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-13614-1_4

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-13613-4

  • Online ISBN: 978-3-319-13614-1

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation