Noninvasive assessment of hepatic decompensation

Non-invasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to symptom-driven assessment of decompensation in cirrhosis patients, NITs not only provide opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision making based on validated cut-offs and standardized interpretations, as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, hepatic encephalopathy, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.