Burden of Portal Hypertension Complications is Greater in Patients with Decompensated Cirrhosis and Type 2 Diabetes Short title: Impact of Diabetes on Outcomes In Cirrhosis

Abstract Background and aims:Impact of type 2 diabetes mellitus (T2DM) in patients with decompensated cirrhosis awaiting liver transplantation (LT) remains poorly defined. The current study hypothesizes, that the presence of T2DM will be associated with worse LT waitlist outcomes that include greater burden of portal hypertension related complications, hospitalizations, and mortality. Methods: In this retrospective study, 593 patients evaluated for LT between 1/2010 to 1/2017 were included in the analysis. The impact of T2DM on portal hypertension, survival, and likelihood of receiving LT were evaluated. Results: The baseline prevalence of T2DM was 32% (n=191). At baseline, patients with T2DM were more likely to have esophageal varices (61% vs. 47%, p=0.002) and history of variceal hemorrhage (23% vs. 16%, p=0.03). T2DM was associated with increase risk of incident ascites (OR 1.91, 95% CI 1.11, 3.28, p=0.019). Patients with T2DM were more likely to require hospitalizations (56% vs. 49%) over 12 months of follow up, however, this did not reach statistical significance (p=0.06). Patients with diabetes were more likely to be hospitalized with portal hypertension related complications (22% vs. 14%; p=0.026) and require renal replacement therapy during their hospitalization. Patients with T2DM were less likely to receive a LT (37% vs. 45%; p=0.03) and had significantly lower bilirubin at each follow up. No differences in INR and creatinine were noted. Conclusion: Patients with T2DM are at increased risk of portal hypertension complications. This risk is not captured in MELD score, which may potentially negatively affect their likelihood of receiving LT.