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The LiverRisk score has been recently developed and validated as a predictor of liver fibrosis and liver-related outcomes in the general population. This score has never been evaluated as predictor of liver fibrosis and outcomes in secondary care, such as in patients with chronic liver diseases. The aim of this study was to evaluate the role of the LiverRisk score as a predictor of liver fibrosis and mortality in patients with HCV-related hepatitis treated with direct acting antivirals (DAA). patients were enrolled retrospectively, outpatients with chronic hepatitis C treated with DAA between 2015 and 2017 were included consecutively. Patients were followed-up until September 2023. The exclusion criteria were: liver transplantation before DAAs and presence of HCC. Patient characteristics and LiverRisk score were collected before starting the DAA. The data for the calculation of LiverRisk score were collected the same day the fibroscan was performed. The primary endpoint was a liver stiffness ≥10 kPa. Area under the receiver operating characteristic (AUROC) curve was evaluated for assessing the discrimination ability of Liver Risk score. Overall mortality was assessed at the end of follow-up. in this ongoing study, 136 patients of our center with chronic hepatitis C treated with DAA were enrolled. In this population, 51% were men, the mean age was 65.3±12.2 years, 65.4% were genotype 1, 59.6% had liver cirrhosis, the mean liver stiffness measurement was 15.9 KPa (3.5-48.8), sustained virological response (SVR) was 95.5% and the mean follow-up was of 59 months. Coinfection with hepatitis B virus (HBV) was present in 8.8%. Discrimination ability of the LiverRisk score in the prediction of liver stiffness ≥10KPa was very good as shown by an AUROC of 0.848 (95% confidence interval [CI] = 0.767-0.930; p=0.000). During follow up 21 patients (15.4%) died. LiverRisk score was associated with the risk of all cause of mortality (Hazard Ratio = 1.154; 95% CI = 1.01–1.318; p = 0.035). the liver risk score is a good predictor of fibrosis and mortality in HCV patients treated with DAA. [ABSTRACT FROM AUTHOR]

The LiverRisk score is a non-invasive test that has been recently proposed for assessing the risk of compensated advanced chronic liver disease and liver-related events in patients without known chronic liver disease. Recently, its diagnostic and prognostic ability in tertiary settings was questioned. The aim of this study was the evaluation of the ability of LiverRisk score in predicting first decompensating event and mortality in outpatients with compensated cirrhosis. 271 outpatients with compensated cirrhosis and different etiologies evaluated at the Care Management Program of the University Hospital of Padova from 2004 to 2023 were enrolled in the study. LiverRisk score was calculated for each patient using biochemical parameters at inclusion. Patients were followed until death, liver transplantation or the end of follow up (October 2023). 271 outpatients (64% males, mean age 56.7±13.0 years, mainly HCV cirrhosis [48.7%], median MELD and CTP 8 and 6, respectively) were included in the study. During follow up, 60 patients developed ascites (22.1%, and 6 developed refractory ascites), 30 hepatic encephalopathy (11.1%), 17 variceal bleeding (6.3%). Fiftysix patients died (20.7%, 33 for hepatic cause) and 31 were transplanted (11.4%). At multivariable analysis (adjusted for age, MELD, varices at inclusion and effective etiological treatment), LiverRisk score was associated with development of decompensation (HR 1.08, 95% CI 1.02-1.14, p=0.015) and in particular with development of ascites (HR 1.07, 95% CI 1.02-1.13, p=0.012), but not with mortality (HR 1.06, 95% CI 0.96-1.18, p=0.245). LiverRisk score is associated with a high risk of decompensation in patients with compensated cirrhosis, however it is not significantly associated with mortality. [ABSTRACT FROM AUTHOR]

MDR bacterial infections are frequent and difficult to treat in patients with cirrhosis. In addition to standard risk factors (epidemiology, antibiotic/healthcare exposure), colonization by MDR may increase the risk of MDR. The screening for rectal colonization by MDR pathogens could be a valuable tool to identify patients with cirrhosis at risk for MDR infection. Assess the prevalence and clinical impact of rectal colonization by MDR organisms in hospitalized patients with acute decompensation (AD) of cirrhosis. Consecutive patients admitted for AD and available rectal swab screening for MDR colonization at admission were enrolled. The following clinical endpoints were assessed: development of bacterial/MDR bacterial infection during hospitalization; transfer to intensive care unit (ICU); development of acute-on-chronic liver failure (ACLF); in-hospital mortality; 28- day mortality; 90-day mortality. 204 patients underwent rectal swab, and 37 (18.1%) tested positive for colonization by MDRO (carbapenem-resistant enterobacteriaceae accounted for 60% of cases). Patients colonized by MDRO had higher incidence of MDR infections (29,2 vs 6,2%; p=0,006), ACLF (43,2 vs 21%; p=0,009), transfer to ICU (16,2 vs 8,4%; p=0,018) and 90 days mortality (51,3 vs 14,3%; p<0,001). Almost two third of MDR infections were sustained by the same pathogen identified in rectal swab. In multivariable analysis, patients with MDR colonization had higher risk of developing MDR infections [HR=5.22; p=0.003], an increased risk of developing ACLF [OR=3.50, p=0.005], of being transferred to the ICU [OR=3.03; p=0.016], and of experiencing mortality during hospitalization [OR=9.38; p<0.001], as well as at 28 days [sHR=5.11; p<0.001] and 90 days [sHR=4.89; p<0.001]. Colonization by MDR organisms is associated with increased risk of developing MDR infections, organ failures and mortality in patients with AD of cirrhosis. Rectal swab could be a valuable screening tool for the clinical management of these patients. [ABSTRACT FROM AUTHOR]

Sarcopenia is frequent in patients with cirrhosis and linked to poor clinical outcomes. Ultrasound measurement of rectus femoris cross sectional area (RF-CSA) is an easy bedside tool for assessing sarcopenia in patients with cirrhosis. The aim of this study was to evaluate the ability of RF-CSA in predicting 90-day readmission in patients hospitalized for an acute decompensation (AD) of cirrhosis. We prospectively enrolled cirrhotic patients surviving a hospitalization for AD between 2019 and 2024. At discharge, clinical, demographic and laboratory data were collected, and RF-CSA was measured at two-thirds of the distance from the anterior superior iliac spine to the superior patellar border. Patients were classified in two groups according to the median values of RF-CSA for males (3.34 cm2) and females (2.42 cm2): "high" if the RF-CSA value was above or equal to the median, and "low" if it was below the median. Follow-up continued until death, liver transplant, or 90 days, during which readmissions were documented. We enrolled 164 patients (mean age 64±10 years, median MELD 16), the majority had alcohol-related cirrhosis (59%) and ascites (70%). During the 90-day follow-up 73 patients were readmitted (45%). They were older (67 vs 62 years; p=0.004) and had lower RF-CSA (2.88 vs 3.63 cm2; p=0.002). Patients with "low" RF-CSA had a higher probability of 90-day readmission than those with "high" RF-CSA (59 vs 36%; p=0.002). In multivariable analysis (adjusted for age, sex, MELD and hepatic encephalopathy), RF-CSA was an independent predictor of 90-day readmission ("high" vs "low" sHR=0.54; p=0.011), along with MELD (sHR=1.05; p=0.037) and age (sHR=1.03; p=0.005). Low muscle mass assessed by RF-CSA independently predicts 90 day-readmission in cirrhotic patients surviving a hospitalization for AD. Preventing muscle loss and/or promoting increases in muscle mass could be potential targets for strategies aimed at preventing readmissions. [ABSTRACT FROM AUTHOR]

With the advancement of artificial intelligence(AI), platforms like ChatGPT have gained traction in different fields, including Medicine. This study aims to evaluate the potential of ChatGPT in addressing questions related to HIV prevention and to assess its accuracy, completeness, and inclusivity. A team consisting of 15 physicians, six members from HIV communities, and three experts in gender and queer studies designed an assessment of ChatGPT. Queries were categorized into five thematic groups: general HIV information, behaviors increasing HIV acquisition risk, HIV and pregnancy, HIV testing, and the prophylaxis use. A team of medical doctors was in charge of developing questions to be submitted to ChatGPT. The other members critically assessed the generated responses regarding level of expertise, accuracy, completeness, and inclusivity. The median accuracy score was 5.5 out of 6, with 88.4% of responses achieving a score ≥ 5. Completeness had a median of 3 out of 3, while the median for inclusivity was 2 out of 3. Some thematic groups, like behaviors associated with HIV transmission and prophylaxis, exhibited higher accuracy, indicating variable performance across different topics. Issues of inclusivity were identified, notably the use of outdated terms and a lack of representation for some communities. ChatGPT demonstrates significant potential in providing accurate information on HIV-related topics. However, while responses were often scientifically accurate, they sometimes lacked the socio-political context and inclusivity essential for effective health communication. This underlines the importance of aligning AI-driven platforms with contemporary health communication strategies and ensuring the balance of accuracy and inclusivity., (© 2024. The Author(s).)

Background & Aims: The prognostic impact of acute decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined non-acute decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis., Methods: A total of 617 outpatients with cirrhosis from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic., Results: During follow-up, 154 patients (25.0% of total patients) developed complications, 69 patients (44.8%) developed NAD and 85 (55.2%) developed AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation than in patients with NAD or AD. On multivariable analysis, AD (hazard ratio [HR] 21.07, p <0.001), NAD (HR 7.13, p <0.001), the etiological cure of cirrhosis (HR 0.38, p <0.001) and model for end-stage liver disease score (HR 1.12, p = 0.003) were found to be independent predictors of mortality., Conclusions: The first decompensation is non-acute in almost 50% of outpatients, though such events are still associated with decreased survival compared to no decompensation. Patients who develop NAD must be treated with extreme care and monitored closely to prevent the development of AD., Impact and Implications: This multicenter study is the first to investigate the role of non-acute decompensation (NAD) in patients with cirrhosis. In fact, while the unfavorable impact of acute decompensation is well known, there is currently a dearth of evidence on NAD, despite it being a common occurrence in clinical practice. Our data show that almost half of decompensations in patients with cirrhosis can be considered NAD and that such events are associated with a higher risk of mortality than no decompensation. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background and Aims: Removal/suppression of the primary etiological factor reduces the risk of decompensation and mortality in compensated cirrhosis. However, in decompensated cirrhosis, the impact of etiologic treatment is less predictable. We aimed to evaluate the impact of etiological treatment in patients with cirrhosis who developed ascites as single index decompensating event., Approach and Results: Patients with cirrhosis and ascites as single first decompensation event were included and followed until death, liver transplantation, or Q3/2021. The etiology was considered "cured" (alcohol abstinence, hepatitis C cure, and hepatitis B suppression) versus "controlled" (partial removal of etiologic factors) versus "uncontrolled." A total of 622 patients were included in the study. Etiology was "cured" in 146 patients (24%), "controlled" in 170 (27%), and "uncontrolled" in 306 (49%). During follow-up, 350 patients (56%) developed further decompensation. In multivariable analysis (adjusted for age, sex, varices, etiology, Child-Pugh class, creatinine, sodium, and era of decompensation), etiological cure was independently associated with a lower risk of further decompensation (HR: 0.46; p = 0.001). During follow-up, 250 patients (40.2%) died, while 104 (16.7%) underwent LT. In multivariable analysis, etiological cure was independently associated with a lower mortality risk (HR: 0.35, p < 0.001)., Conclusions: In patients with cirrhosis and ascites as single first decompensating event, the cure of liver disease etiology represents a main treatment goal since this translates into considerably lower risks of further decompensation and mortality., (Copyright © 2023 American Association for the Study of Liver Diseases.)

Background & Aims: Bacterial infections are frequent in patients with cirrhosis and increase the risk of death and drop-out from liver transplant (LT) waiting list. In patients with bacterial infections, LT is frequently delayed because of the fear of poor outcomes. We evaluated the impact of pre-LT infections on post-LT complications and survival., Methods: From 2012 to 2018, consecutive patients transplanted at the Hospital of Padua were identified and classified in two groups: patients surviving an episode of bacterial infection within 3 months before LT (study group) and patients without infections before LT (control group). Post-LT outcomes (complications, new infections, survival) were collected., Results: A total of 466 LT recipients were identified (study group n = 108; control group n = 358). After LT, the study group had a higher incidence of new bacterial (57% vs. 20%, p <0.001) and fungal infections (14% vs. 5%, p  = 0.001) and of septic shock (8% vs. 2%, p  = 0.004) than the control group. Along with the model for end-stage liver disease (MELD) score and alcohol-related cirrhosis, bacterial infection pre-LT was an independent predictor of post-LT infections (odds ratio = 3.92; p <0.001). Nevertheless, no significant difference was found in 1-year (88% vs. 89%, p  = 0.579) and 5-year survival rates (76% vs. 75%, p  = 0.829) between the study group and control group. Within the study group, no association was found between the time elapsed from infection improvement/resolution to LT and post-LT outcomes., Conclusions: Patients with pre-LT infections have a higher risk of new bacterial and fungal infections and of septic shock after LT. However, post-LT survival is excellent. Therefore, as soon as the bacterial infection is improving/resolving, transplant should not be delayed, but patients with pre-transplant bacterial infections require active surveillance for infections after LT., Impact and Implications: Bacterial infections increase mortality and delay transplant in patients with cirrhosis awaiting liver transplantation (LT). Little is known about the impact of adequately treated infections before LT on post-transplant complications and outcomes. The study highlights that pre-LT infections increase the risk of post-LT infections, but post-LT survival rates are excellent despite the risk. These findings suggest that physicians should not delay LT because of concerns about pre-LT infections, but instead should actively monitor these patients for infections after surgery., Competing Interests: The authors have nothing to disclose regarding the work under consideration for publication. The following authors disclose conflicts of interests outside the submitted work: SI, MT, NZ, CG, RG, VC, AB. PB, UC, PA received grant/research support from Grifols and CSL Behring; held a patent with Biovie; served as consulting for Sequana Medical. SP received advisory board fees from Mallinckrodt, consulting fees from Plasma Protein Therapeutics Association and Resolution Therapeutics, and speaking fees from Grifols. Please refer to the accompanying ICMJE disclosure forms for further details., (© 2023 The Author(s).)

Background and Aims: Acute kidney injury (AKI) commonly occurs in patients with decompensated cirrhosis. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) could help discriminate between different etiologies of AKI. The aim of this study was to investigate the use of uNGAL in (1) the differential diagnosis of AKI, (2) predicting the response to terlipressin and albumin in patients with hepatorenal syndrome-AKI (HRS-AKI), and (3) predicting in-hospital mortality in patients with AKI., Approach and Results: One hundred sixty-two consecutive patients with cirrhosis and AKI were included from 2015 to 2020 and followed until transplant, death, or 90 days. Standard urinary markers and uNGAL were measured. Data on treatment, type, and resolution of AKI were collected. Thirty-five patients (21.6%) had prerenal AKI, 64 (39.5%) HRS-AKI, 27 (16.7%) acute tubular necrosis-AKI (ATN-AKI), and 36 (22.2%) a mixed form of AKI. Mean values of uNGAL were significantly higher in ATN-AKI than in other types of AKI (1162 ng/ml [95% CI 423-2105 ng/ml] vs. 109 ng/ml [95% CI 52-192 ng/ml]; p  < 0.001). uNGAL showed a high discrimination ability in predicting ATN-AKI (area under the receiver operating characteristic curve, 0.854; 95% CI 0.767-0.941; p  < 0.001). The best-performing threshold was found to be 220 ng/ml (sensitivity, 89%; specificity, 78%). The same threshold was independently associated with a higher risk of nonresponse (adjusted OR [aOR], 6.17; 95% CI 1.41-27.03; p  = 0.016). In multivariable analysis (adjusted for age, Model for End-Stage Liver Disease, acute-on-chronic liver failure, leukocytes, and type of AKI), uNGAL was an independent predictor of in-hospital mortality (aOR, 1.74; 95% CI 1.26-2.38; p  = 0.001)., Conclusions: uNGAL is an adequate biomarker for making a differential diagnosis of AKI in cirrhosis and predicting the response to terlipressin and albumin in patients with HRS-AKI. In addition, it is an independent predictor of in-hospital mortality., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background & Aims: Although ascites is the most frequent first decompensating event in cirrhosis, the clinical course after ascites as the single index decompensation is not well defined. The aim of this multicentre study was thus to systematically investigate the incidence and type of further decompensation after ascites as the first decompensating event and to assess risk factors for mortality., Methods: A total of 622 patients with cirrhosis presenting with grade 2/3 ascites as the single index decompensating event at 2 university hospitals (Padova and Vienna) between 2003 and 2021 were included. Events of further decompensation, liver transplantation, and death were recorded., Results: The mean age was 57 ± 11 years, and most patients were male (n = 423, 68%) with alcohol-related (n = 366, 59%) and viral (n = 200,32%) liver disease as the main aetiologies. In total, 323 (52%) patients presented with grade 2 and 299 (48%) with grade 3 ascites. The median Child-Pugh score at presentation was 8 (IQR 7-9), and the mean model for end-stage liver disease (MELD) was 15 ± 6. During a median follow-up period of 49 months, 350 (56%) patients experienced further decompensation: refractory ascites (n = 130, 21%), hepatic encephalopathy (n = 112, 18%), spontaneous bacterial peritonitis (n = 32, 5%), hepatorenal syndrome-acute kidney injury (n = 29, 5%). Variceal bleeding as an isolated further decompensation event was rare (n = 18, 3%), whereas non-bleeding further decompensation (n = 161, 26%) and ≥2 concomitant further decompensation events (n = 171, 27%) were frequent. Transjugular intrahepatic portosystemic shunt was used in only 81 (13%) patients. In patients presenting with grade 2 ascites, MELD ≥15 indicated a considerable risk for further decompensation (subdistribution hazard ratio [SHR] 2.18; p <0.001; 1-year incidences: <10: 10% vs . 10-14: 13% vs . ≥15: 28%) and of mortality (SHR 1.89; p  = 0.004; 1-year incidences: <10: 3% vs . 10-14: 6% vs. ≥15: 14%). Importantly, mortality was similarly high throughout MELD strata in grade 3 ascites ( p  = n.s. for different MELD strata; 1-year incidences: <10: 14% vs. 10-14: 15% vs . ≥15: 20%)., Conclusions: Further decompensation is frequent in patients with ascites as a single index decompensation event and only rarely owing to bleeding. Although patients with grade 2 ascites and MELD <15 seem to have a favourable prognosis, those with grade 3 ascites are at a high risk of mortality across all MELD strata., Lay Summary: Decompensation (the development of symptoms as a result of worsening liver function) marks a turning point in the disease course for patients with cirrhosis. Ascites ( i.e. , the accumulation of fluid in the abdomen) is the most common first decompensating event, yet little is known about the clinical course of patients who develop ascites as a single first decompensating event. Herein, we show that the severity of ascites is associated with mortality and that in patients with moderate ascites, the widely used prognostic MELD score can predict patient outcomes., Competing Interests: The authors have nothing to disclose regarding the work under consideration for publication. The following authors disclose conflicts of interests outside the submitted work: LB, MTo, GS, VC, LH, SI, MJ, BSH, CGC, AA, AB, and SP have nothing to disclose. DB received travel support from AbbVie and Gilead and speaker fees from AbbVie and Siemens, as well as grant support form Gilead and Siemens. MTr received grant support from Albireo, Alnylam, Cymabay, Falk, Gilead, Intercept, MSD, Takeda, and UltraGenyx; honouraria for consulting from Albireo, Boehringer Ingelheim, BiomX, Falk, Genfit, Gilead, Intercept, Janssen, MSD, Novartis, Phenex, Pliant, Regulus, and Shire; speaker fees from Bristol-Myers Squibb, Falk, Gilead, Intercept, and MSD; and travel support from AbbVie, Falk, Gilead, and Intercept. MM served as a speaker and/or consultant and/or advisory board member for AbbVie, Collective Acumen, Gilead, and W.L. Gore & Associates and received travel support from AbbVie and Gilead. TR received grant support from AbbVie, Boehringer-Ingelheim, Gilead, Intercept, MSD, Myr Pharmaceuticals, Philips Healthcare, Pliant, Siemens, and W.L. Gore & Associates; speaking honoraria from AbbVie, Gilead, Gore, Intercept, Roche, and MSD; consulting/advisory board fees from AbbVie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, and Siemens; and travel support from AbbVie, Boehringer-Ingelheim, Gilead, and Roche. Please refer to the accompanying ICMJE disclosure forms for further details., (© 2022 The Author(s).)

Background and Aims: Although terlipressin and albumin are effective at treating acute kidney injury-hepatorenal syndrome (AKI-HRS), liver transplantation (LT) is the best treatment. However, it is unclear if an effective treatment with terlipressin and albumin improves post-LT outcomes in these patients. The aim of this study was to evaluate the impact of response to treatment with terlipressin and albumin on posttransplant outcomes in patients with AKI-HRS., Approach and Results: We analyzed two cohorts of patients with cirrhosis listed for LT between 2012 and 2016: 82 patients who developed AKI-HRS before LT and were treated with terlipressin and albumin and 259 patients without AKI-HRS who received transplants during the study period (control group). After LT, patients were followed up until discharge, every month for the first 3 months, and every 3 months thereafter. Of the patients, 43 (52%) responded to terlipressin and albumin. Responders had a better 30-day transplant-free survival (60% vs. 33%, P = 0.006), longer LT waiting list time (37 vs. 17 days, P = 0.041), and lower Model for End-Stage Liver Disease score at the time of LT (23 vs. 29, P = 0.007). Among patients with AKI-HRS receiving transplant, nonresponders required renal replacement therapy (RRT) more frequently than responders (20% vs. 0%, P = 0.024). Nonresponders had a significantly higher incidence of chronic kidney disease (CKD) at 1 year after LT than responders (65% vs. 31%, P = 0.019). In multivariate analysis, nonresponse to terlipressin and albumin was found to be an independent predictor for CKD at 1 year after LT (subdistribution hazard ratio [SHR] = 2.76, P = 0.001), whereas responders did not have an increased risk (SHR = 1.53, P = 0.210)., Conclusions: In patients with AKI-HRS, response to terlipressin and albumin reduces the need for RRT after LT and reduces the risk of CKD at 1 year after LT., (© 2020 by the American Association for the Study of Liver Diseases.)

Background & Aims: In 2012, the KDIGO group proposed new definitions for acute kidney injury (AKI), acute kidney disease (AKD) and chronic kidney disease (CKD). According to the definition adapted by the International Club of Ascites, AKI has been extensively investigated in patients with cirrhosis. On the contrary, there are currently no data on the epidemiology and clinical outcomes associated with AKD. The aim of the study was to assess the prevalence and the impact of AKD on the clinical course and survival of patients with cirrhosis., Methods: A total of 272 consecutive patients with cirrhosis attending our outpatient clinic were included in the study. Clinical and laboratory data were collected at inclusion. Patients were followed-up until death, liver transplant or the end of follow-up., Results: During follow-up, 80 patients developed AKD (29.4%). Forty-two (52.5%) recovered from the first episode of AKD and 26 maintained a normal renal function up to the end of follow-up. Sixteen patients developed a second episode of AKD. Globally, 36 patients (45.0%) died with AKD. Finally, AKD progressed to CKD in 11 patients (13.8%). The 5-year survival rate was significantly lower in patients who developed AKD than in those who did not (34.8% vs. 88.8%, p <0.001). The 5-year rates of complications of cirrhosis and of hospitalizations were also higher in patients with AKD than in those without AKD., Conclusions: AKD is frequent in patients with cirrhosis. It can be reversible, but it may recur and progress to CKD. AKD has a very negative impact on morbidity and mortality in patients with cirrhosis., Lay Summary: Renal impairment has a very negative impact on patients with cirrhosis. Renal impairment seems to be characterized by a very dynamic course, which is defined according to renal function and length of the impairment as acute kidney injury, acute kidney disease and chronic kidney disease. The role of acute kidney disease is currently unknown. Our study shows for the first time that acute kidney disease is frequent in patients with cirrhosis and has a very negative impact on survival., Competing Interests: Conflict of interest The authors of this manuscript have no conflict of interest to declare. Please refer to the accompanying ICMJE disclosure forms for further details., (Copyright © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)