a novel combinatorial therapy with albumin and enoxaparin in patients with decompensated cirrhosis at high-risk of poor outcome (combat trial).

Conditions: Liver Cirrhosis; Decompensated Cirrhosis of Liver; Acute on Chronic Liver Failure (ACLF)

Summary: the goal of this clinical trial is to determine primarily whether a combinatorial therapy based on the administration of human albumin and enoxaparin is safe and effective in patients with decompensated cirrhosis discharged from the hospital. the main questions it aims to answer are: * is this combinatorial therapy safe and tolerable? * is this combinatorial therapy effective? * does this combinatorial therapy cost more or less than standard medical therapy? participants will attend to study visits in which several test will be performed to asses disease evolution while they are taking study medication. researchers will compare experimental group treated with combinatorial therapy plus standard treatment with control group treated with standard treatment to see if there are differences in the responses to the questions raised above.


Eligibility criteria:
inclusion criteria: 1. age between 18 and 80 years. 2. patients with decompensated cirrhosis admitted to hospital due to ad according to the easl-clif criteria (rapid onset of ascites, hepatic encephalopathy, portal hypertensive-related gastrointestinal bleeding, bacterial infection, or any combination of these). 3. clif-c ad score ≥ 45 at admission or at any time during hospital stay. 4. recovery from ad and expected to be discharged within the next 72 hours. exclusion criteria: 1. diagnosis of acute-on-chronic liver failure (aclf) grade 3 or higher according to the easl-clif criteria at admission or at any time during the index hospitalization 2. admission for planned diagnostic or therapeutic procedures 3. recent acute bleeding (unless the cause has been effectively treated and there is no evidence of ongoing bleeding for at least 5 days) 4. chronic bleeding requiring periodic blood transfusions 5. presence of an ongoing acute complication of the disease (i.e. hepatic encephalopathy \[grade iii or iv\]) 6. conditions with a high risk of haemorrhage, including haemorrhagic diathesis not related to liver disease 7. patients with inr \> 3.0 8. severe thrombocytopenia (\<30x10 9 /l) 9. ongoing chronic anticoagulation therapy or indication for starting anticoagulation due to hepatic and non-hepatic conditions 10. ongoing anti-platelets therapy. 11. active malignancy (except for hepatocellular carcinoma within the milan criteria or non-melanocytic skin cancer) 12. antiviral treatment for hepatitis c, b and delta initiated in the last 6 months or planned to be initiated in the following 6 months 13. ongoing alcohol use disorder with an expected low adherence to protocol as judged by physician 14. previous liver transplantation 15. patients with tips or other surgical porto-caval shunts 16. chronic organic renal failure stage iv and v or estimated glomerular filtration rate \<30 ml/min according to the mdrd equations 17. chronic heart failure nyha class iii or iv 18. pulmonary disease gold iii or iv 19. patients with extrahepatic diseases with life expectancy \<6 months 20. severe psychiatric disorders 21. hypersensitivity to albumin preparations or to any of the excipients. 22. hypersensitivity to enoxaparin sodium, heparin or its derivatives, including other low molecular weight heparins (lmwh) or to any of the excipients 23. history of immune mediated heparin-induced thrombocytopenia (hit) within the past 100 days or in the presence of circulating antibodies 24. pregnancy and breast-feeding 25. expected low adherence to study protocol as judged by physician 26. patients who can't provide written informed consent or refusal to participate 27. participation in other concurrent clinical trials and within the prior 3 months from informed consent signature.

Keywords: decompensated cirrhosis acute on chronic liver failure (aclf) liver diseases liver cirrhosis human albumin enoxaparin