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The clinical course of patients with liver cirrhosis and adherence to hepatocellular carcinoma (HCC) screening guidelines are not well studied in the Netherlands. We investigated this and potential risk factors for decompensation and transplant-free survival (TFS) in a large regional cohort. We performed a retrospective cohort study of patients with confirmed liver cirrhosis in Amsterdam, the Netherlands. Clinical parameters, decompensation events, development of HCC, and medication use were extracted from medical records. In total, 681 hospitalized and outpatients were included. Mortality risk was increased by: age (aHR 1.07,  p &lt; 0.01 ), smoking (aHR 1.83,  p &lt; 0.01 ), decompensated initial presentation (aHR 1.43,  p = 0.04 ) and increased MELD (aHR 1.07,  p &lt; 0.01 ). PPI use tended to increase mortality risk (aHR 1.35,  p  = 0.05). The risk of future decompensation was increased with increased age (aHR 1.02,  p &lt; 0.01 ), decompensated initial presentation (aHR 1.37,  p = 0.03 ) and alcohol misuse as etiology (aHR 1.34,  p = 0.04 ). Adequately screened patients for HCC had a longer TFS compared to patients who were not (48 vs 22 months),  p &lt; 0.01 ). In patients with cirrhosis, decompensation at initial presentation was associated with an increased risk of future decompensation and mortality. Alcoholic cirrhosis was associated with an increased risk of future decompensation. Adequate HCC surveillance was associated with markedly better survival.

Decompensation as initial presentation in patients with liver cirrhosis is associated with an increased risk of future decompensation and mortality