Review for 10.1186/s12876-024-03494-3 (2024)

Title: Risk factors and prognostic impact of new decompensated events in hospitalized patients
with decompensated cirrhosis
Version: 1 Date: 28 Sep 2024
Reviewer's report:
Dear colleague
1. Infections are not described as part of cirrhosis decompensation according to the Baveno VII
guidelines:
The article includes infections, specifically bacterial ones, as decompensation events in cirrhotic
patients. However, this is not consistent with the definitions accepted in the Baveno VII
guidelines. According to these guidelines, cirrhosis decompensations include events such as
ascites, hepatic encephalopathy, gastrointestinal bleeding, and in some cases, jaundice in the
context of non-cholestatic liver disease. Infections, whether bacterial, viral, or opportunistic,
are serious complications in patients with cirrhosis, but they are not considered primary
decompensations of the disease. By including infections of any type as decompensation events,
the study may be overestimating the rate of decompensation and creating confusion about the
true progression of cirrhosis.
2. Diagnosing decompensation within 48 hours of admission seems premature, as infections or
other complications may be diagnosed later:
The study considers any decompensation occurring after 48 hours of admission as a new event,
which appears to be too short of a time frame for many clinical diagnoses. In medical practice,
infections caused by various microorganisms—such as bacteria, viruses, or fungi—can be
diagnosed beyond this time frame, especially when additional microbiological tests are required.
Treating the initial decompensation (e.g., ascites) and an infection diagnosed later as separate
events introduces a bias in the interpretation of the clinical course. In many cases, the infection
is the underlying cause that precipitates the initial decompensation, so treating these as distinct
events underestimates the underlying causal sequence. This could lead to an overestimation of
new decompensations, potentially influencing the study’s conclusions regarding mortality and
other clinical
3- This article highlights several clinically relevant findings, particularly regarding renal failure
and elevated levels of C-reactive protein (CRP) as key factors in the development of infections
in patients with decompensated cirrhosis. Renal failure, a common complication in advanced
cirrhosis, is strongly associated with a worse prognosis and increased vulnerability to infections.
This connection further exacerbates the clinical condition of patients, underscoring the need for
close monitoring of renal function.
The study also points out that elevated CRP levels, a sensitive marker of systemic inflammation,
are significantly associated with a higher risk of developing infections. CRP not only reflects the
presence of infections but also their severity, making it a key parameter for clinical monitoring.
These findings highlight the importance of the inflammatory state in the progression of cirrhosis
and its impact on mortality.
An additional important aspect to consider in clinical practice is the implementation of empirical
antibiotic treatments in patients with decompensated cirrhosis who present with renal failure
or elevated CRP levels, as both factors predict a higher risk of infections. Early administration
of antibiotics could significantly improve clinical outcomes in these patients by preventing the
progression of infections and improving short-term survival.