Recompensation After Etiologic Cure in United States Veterans With Hepatitis C Virus-Related Decompensated Cirrhosis

Recompensation after etiologic cure is increasingly recognized as an achievable state in decompensated cirrhosis, but United States data remain limited. We evaluated the frequency, predictors, and prognostic relevance of recompensation after hepatitis C virus (HCV) cure in United States Veterans with HCV-related decompensated cirrhosis.

We performed a retrospective cohort study using the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) cohort. Patients with HCV-related cirrhosis, imaging-documented ascites before direct-acting antiviral therapy, and sustained virologic response were included. The primary outcome was recompensation (per Baveno VII criteria) during follow-up. Fine-Gray regression was used for univariable and multivariable analyses of predictors of recompensation, with death or liver transplantation as competing events. A 24-month landmark analysis assessed subsequent all-cause mortality (Cox regression) and hepatocellular carcinoma (Fine-Gray regression). A separate Fine-Gray analysis evaluated time to documented ascites resolution.

Among 1213 eligible patients, 163 (13%) achieved recompensation up to 24 months after direct-acting antiviral initiation. In multivariable analysis, higher baseline albumin independently predicted recompensation, whereas platelet count <110 × 10⁹/L and further decompensation were associated with a lower likelihood of recompensation. Recompensation was associated with reduced subsequent all-cause mortality. Predictors of documented ascites resolution were similar to those of recompensation.

Recompensation occurs in a meaningful proportion of patients with HCV-related decompensated cirrhosis after sustained virologic response and is associated with improved survival. Patients with preserved liver synthetic function and less severe portal hypertension are more likely to recompensate, whereas further decompensation reduces this likelihood. Ascites resolution alone identified most patients achieving Baveno VII-defined recompensation, suggesting it may serve as a pragmatic clinical marker of recompensation.