The Gut Microbiome in Liver Cirrhosis: Stage-Specific Alterations and Therapeutic Strategies

Liver cirrhosis represents a significant global health burden, and its progression is closely linked to dysregulation of the gut‒liver axis. Accumulating evidence reveals stage-specific alterations in gut microbiota throughout the disease continuum. Microbial diversity decreases starting in the compensated stage, whereas the decompensated stage is characterized by marked enrichment of opportunistic pathogens, a decline in protective metabolites, and impaired microbial metabolic and barrier-related functions. These changes are implicated in the pathogenesis of complications such as hepatic encephalopathy and spontaneous bacterial peritonitis. In clinical management, the combination of lactulose and rifaximin serves as the cornerstone for preventing and treating hepatic encephalopathy, while probiotics and fecal microbiota transplantation have emerged as promising therapeutic adjuncts or alternatives. For prevention and management of spontaneous bacterial peritonitis, specific probiotics may serve as an adjunctive strategy. Despite these advances, the field faces challenges, including methodological heterogeneity and gaps in translational research. Future research must prioritize standardizing methodologies, implementing long-term longitudinal cohorts and integrating multiomics data to develop a precision management framework tailored to disease stages. Such efforts are crucial for redefining cirrhosis as a controllable and potentially reversible chronic condition.