Natural history of clinical outcomes and hepatic decompensation in metabolic dysfunction‐associated steatotic liver disease

Summary Background & Aims The natural progression of hepatic decompensation in metabolic dysfunction‐associated steatotic liver disease (MASLD) is not well‐characterised. We aimed to describe it by conducting a retrospective analysis. Methods This longitudinal, retrospective analysis of well‐characterised MASLD cohorts followed for hepatic decompensation and death. The sequence of liver‐related events was evaluated, and the median time between hepatic decompensation episodes and death versus. transplantation was measured. Results Of the 2016 patients identified, 220 (11%) developed at least one episode of hepatic decompensation during a median follow‐up of 3.2 years. Ascites was the most common first liver‐related event 153 (69.5%), followed by hepatic encephalopathy (HE) 55 (25%) and variceal haemorrhage (VH) 30 (13.6%). Eighteen out of the 220 (8.1%) patients had more than one liver‐related event as their first hepatic decompensation. Among the patients who had the first episode, 87 (39.5%) had a second episode 44 (50.5%) HE, 31 (35.6%) ascites, and 12 (13.7%) VH. Eighteen out of 220 (8.1%) had a third episode 10 (55.5%) HE, 6 (33.3%) VH, and 2 (11.1%) ascites. Seventy‐three out of 220 (33.1%) died, and 31 (14%) received liver transplantation. The median time from the first episode to the second was 0.7 years and 1.3 years from the second episode to the third. The median survival time from the first episode to death or transplantation was 2.0 years. Conclusion The most common first liver‐related event in MASLD patients is ascites. The median survival from the first hepatic decompensation to either death or transplantation is 2 years.