Future directions in noninvasive prediction of cirrhosis decompensation: An opinion review

Cirrhosis is the terminal stage of chronic liver disease. The characteristic manifestations of decompensated cirrhosis are portal hypertension (PH) and complications arising from liver dysfunction, at which stage patient survival is markedly reduced. Hepatic venous pressure gradient serves as the gold standard for assessing PH, with values reaching or exceeding 10 mmHg defining clinically significant PH. Nevertheless, hepatic venous pressure gradient measurement is invasive and limited by high cost, restricted accessibility, and operator dependence, which hinder its routine clinical application. Liver stiffness and spleen stiffness measured via transient elastography have emerged as essential tools for noninvasive risk stratification in chronic liver disease. However, existing noninvasive predictive models are constrained by single-center retrospective designs, homogeneous etiologies, and insufficient standardization of spleen stiffness measurement, and their applicability in patients with hepatocellular carcinoma remains uncertain. Furthermore, the neglect of competing risks in traditional survival analyses has led to overestimation of hepatocellular carcinoma risk. Although technologies such as radiomics and machine learning show considerable promise, prospective multicenter validation remains necessary. Further progress will depend on standardized multi-etiology and multicenter cohorts, supported by rigorous internal and external validation, to produce a universal noninvasive tool for clinical decision-making.