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Recompensation of decompensated cirrhosis in a spectrum of metabolic dysfunction-related steatotic liver disease, with PEth-corroborated alcohol abstinence and modification of cardiometabolic risk factors
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July 17, 2026
Background and Aims:
Recompensation of decompensated metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatotic liver disease with alcohol consumption (MetALD) cirrhosis remains unknown.
Approach:
We assessed rates and predictors of recompensation (Baveno VII criteria) and outcomes after modifiable interventions, including alcohol abstinence, dry-weight loss, and cardiometabolic risk factor management, in a cohort of patients with decompensated MASLD/MetALD cirrhosis between October 2019 and March 2025.
Results:
Among 344 patients with steatotic liver disease-related cirrhosis (mean MELD-Na 14.7±3.6; MASLD-158, MetALD-186), 64(18.6%) achieved recompensation; MASLD (17.7%) and MetALD (19.4%), at a median of 15 months(IQR: 14.5-15.5) over 3.9 years (IQR: 2.8-4) follow-up. Baseline phosphatidylethanol (PEth) was negative in MASLD but positive in 69.4% of MetALD patients (p=0.001). In all, 61 patients (17.7%) died, 11 (3.2%) underwent liver transplantation, and 5 (1.5%) developed hepatocellular carcinoma.
Mortality was lower in MASLD than in MetALD (12.0% vs. 22.6%; p=0.011). In competing-risk regression adjusted for baseline MELD-Na, absence of large esophageal varices (sHR 1.97, 95% CI: 1.22-3.99; p=0.021), weight loss ≥10% (sHR 7.42, 95% CI: 3.15-17.47; p<0.001), alcohol abstinence (sHR 1.87, 95% CI: 1.29-3.32; p=0.003), and glycemic control (sHR 1.43, 95% CI: 1.03-2.79; p=0.038) were associated with recompensation. Higher MELD-Na (sHR 1.13, 95% CI: 1.06-1.2; p<0.001), MetALD etiology (sHR 1.87, 95% CI: 1.09-3.22; p=0.023), lack of recompensation (p<0.001), and ongoing alcohol consumption (sHR 5.3, 95% CI: 2.85-9.74; p<0.001) were associated with mortality.
Conclusions:
PEth improved the ascertainment of alcohol exposure and phenotyping of MASLD and MetALD. Weight loss ≥10%, achievement of glycemic control, and absence of large varices were independently associated with recompensation, which occurred in 18.6% of patients with decompensated MASLD/MetALD cirrhosis.
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