D-LIVER

The challenge

In liver cirrhosis, clinical deterioration often occurs between routine assessments, making early detection of disease progression and associated frailty difficult. Patients with compensated cirrhosis may appear stable during clinic visits yet experience gradual functional decline at home. The transition from compensated to decompensated cirrhosis represents a critical turning point, associated with significantly increased morbidity and mortality.

Traditional evaluations provide only intermittent snapshots and may miss subtle but clinically relevant changes in physical function, sleep quality or activity patterns that could signal impending decompensation. Frailty, increasingly recognised as an important prognostic factor in cirrhosis, is typically assessed using clinic-based performance tests that may not reflect real-world functional capacity. Healthcare providers managing cirrhosis patients need more granular, continuous data to guide timely interventions and prevent complications.

The project: D-LIVER

D-LIVER is a prospective observational pilot study conducted at Medisch Spectrum Twente in collaboration with the University of Twente and TNO. The study was designed to establish the feasibility of continuous wearable monitoring in cirrhosis patients and to identify digital biomarkers associated with disease severity and frailty.

Adults with compensated or decompensated liver cirrhosis wore medical-grade wrist and waist devices continuously for seven days, capturing physiological signals, activity levels, sleep architecture and detailed gait characteristics in their daily environment. This multimodal approach enabled comprehensive assessment of patients' functional status outside the clinical setting. Wearable data were combined with standardised clinical assessments, including liver disease severity scores and established frailty measures, to create a rich dataset linking objective digital measures with clinical status. In addition, patients evaluated the usability of the tested wearables to determine the feasibility of implementing these devices.

TNO led the data analysis and digital biomarker development, applying signal processing and statistical methods to extract meaningful features from the continuous wearable data. The study identified wearable-derived measures that are different during compensated from decompensated cirrhosis and correlate with established clinical and frailty indicators, demonstrating the potential value of continuous, non-invasive monitoring in this patient population. In addition, usability ratings were high, with compliance exceeding 90% for both wearables, rendering the feasibility of employing these devices in this patient population high. These preliminary findings suggest that specific patterns in activity, sleep and gait may serve as early warning signals for clinical deterioration.

Looking to the future

The validated digital biomarkers from D-LIVER provide a foundation for larger prospective studies examining whether continuous monitoring can predict decompensation events before they become clinically apparent. Future research will focus on developing predictive models that integrate wearable data with clinical parameters to identify high-risk patients requiring intensified monitoring or intervention.

Implementation in routine cirrhosis care could enable earlier detection of frailty progression, more personalised management strategies and potentially improved patient outcomes. Collaboration between hepatology centres, wearable technology developers and health systems will be essential to translate these research findings into clinical practice and demonstrate value for patients and healthcare providers.