Clinical Impact and Therapeutic Management of Diabetes Mellitus in Patients With Decompensated Cirrhosis

Diabetes mellitus (DM) affects a substantial proportion of individuals with cirrhosis, with the highest prevalence observed in those with metabolic dysfunction-associated steatotic liver disease (MASLD). Its frequency increases in parallel with declining hepatic function, irrespective of the underlying aetiology. In this setting, both classical type 2 diabetes mellitus (T2DM) and hepatogenous diabetes, which arises secondary to hepatic dysfunction, may occur. T2DM and insulin resistance play key roles in the pathogenesis of MASLD, in the progression of hepatic fibrosis, and in the onset of cirrhosis-related complications through mechanisms encompassing systemic inflammation, endothelial dysfunction, and worsening of portal hypertension. Indeed, DM has been shown to be associated with worse prognosis, including increased rates of hepatic decompensation, higher mortality, and poorer post-liver transplantation outcomes. Achieving adequate glycaemic control may therefore reduce the risk of decompensation and improve overall prognosis. This narrative review examines DM in the context of decompensated cirrhosis, addressing diagnostic challenges, clinical implications, and therapeutic strategies. Particular attention is given to the complexities of antidiabetic management in the presence of impaired liver function, including drug repurposing and the development of agents with potential hepatoprotective effects.