- Design
- Prospective multinational cohort with stool metagenomics
- Population
- 679 outpatients with cirrhosis in seven countries
- Primary outcome
- Non-elective admission within 90 days
- Effect
- 25% admitted; clinical + microbiome AUC 0.84 vs clinical 0.79
A seven-country study profiled stool metagenomes in 679 outpatients with cirrhosis and followed them for 90 days. One in four needed an unplanned admission.
Those admitted had more advanced liver disease and lower microbial diversity, a pattern consistent across countries despite very different gut communities. After adjustment for country, severity, cause and treatment, 19 species were independently associated with admission, including more Enterococcus faecium and fewer short-chain fatty acid producers, along with shifts in carbohydrate metabolism and antibiotic resistance genes. A model combining clinical and microbiome data predicted admission better (AUC 0.84) than clinical data alone (0.79).
This is association, not cause, and stool metagenomics is not a clinical test. Its interest is in pointing to the gut as a target — through rifaximin, lactulose, careful antibiotic use and diet — in patients already at high risk.
- Use MELD, Child-Pugh and recent admissions to identify cirrhosis patients at high risk of readmission
- Avoid unnecessary antibiotics and proton pump inhibitors, both linked to gut dysbiosis
- Keep lactulose and rifaximin going where indicated for hepatic encephalopathy
- Review nutrition, including protein and fibre intake, at each visit
Why it matters
It strengthens the case that gut dysbiosis tracks with decompensation, independent of disease severity.
Don't overread it
The microbiome was associated with admission; the study cannot show that changing it would prevent one.
The statistics, in plain English
An AUC of 0.84 means that, given one admitted and one non-admitted patient, the model ranks them correctly 84% of the time, against 79% for clinical data alone. A modest gain that needs external validation.
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