Risk stratification of non-acute decompensation in alcohol-related cirrhosis using the red cell distribution width-to-platelet ratio.

BACKGROUND & AIMS: Patients with alcohol-related decompensated advanced chronic liver disease and ongoing non-acute decompensation remain at substantial risk of short-term progression to hospitalization-requiring acute decompensation. Early identification of high-risk patients remains challenging. We evaluated whether the red cell distribution width-to-platelet ratio predicts short-term acute decompensation in this vulnerable population. METHODS: In this prospective multicentre study, 260 patients with alcohol-related decompensated advanced chronic liver disease and ongoing non-acute decompensation were enrolled in a derivation cohort and followed for 3 months. The primary outcome was progression to hospitalization-requiring acute decompensation. Predictive performance was assessed using receiver operating characteristic analysis, bootstrap internal validation, Cox regression, and external validation in an independent cohort of 75 patients. RESULTS: During follow-up, 100 patients (38.5%) progressed to acute decompensation. The red cell distribution width-to-platelet ratio showed the highest discriminative performance among all evaluated non-invasive tests (AUC 0.888). The optimal threshold was 0.159, yielding 90.0% sensitivity, 78.1% specificity, and 92.6% negative predictive value. Higher values remained independently associated with acute decompensation (adjusted HR 1.040 per 0.01 increase; 95% CI 1.021-1.060; p < 0.001). External validation confirmed robust performance (AUC 0.836; negative predictive value 95.3%). CONCLUSIONS: The red cell distribution width-to-platelet ratio is a simple, inexpensive biomarker that predicts short-term acute decompensation and may support early outpatient risk stratification.