My heart,
Where either I must live or bear no life,
The fountain from which my current runs
Or dries up
William Shakespeare, Othello

Cirrhosis is a fatal condition. Although mild cirrhosis can be associated with prolonged survival, most diseases that induce cirrhosis progress, at variable rates, to end-stage liver failure. Deaths from hepatic failure, variceal bleeding and infection are common in advanced cirrhosis, and even the rate of sudden unexplained death is increased compared with that in a normal population.¹ Moreover, patients with cirrhosis are well known to be fragile, and do poorly after invasive or stressful procedures. It is logical and intuitive to assume that the sickest patients—that is, those with the most advanced degree of liver failure—will have the poorest outcome after challenges. Indeed, this is what virtually all studies on risk factors for morbidity and mortality in cirrhosis show.² Mortality following a variceal bleed is strongly correlated with the degree of liver dysfunction as estimated by the Child–Pugh score, with death rates of 10–15% in class A, 20–30% in class B and 40–50% in class C patients. Similar correlations have been shown using the Model End-stage Liver Disease (MELD) score to estimate liver function. Cardiovascular surgery carries greater risks in those with advanced liver dysfunction than in those with mild liver dysfunction.³

In all these studies, the assumption was made that deaths were wholly or predominantly due to liver failure. Indeed, a recent exhaustive systematic review of the entire world literature to 2006, analysing 118 studies that examined risk factors predictive of death in patients with cirrhosis, found that liver function, as assessed by the Child–Pugh score or the MELD score, consistently emerged as the best predictor of mortality in the majority of …