The study investigates changes in the gut microbiome in patients with cirrhosis and its complications. It defines the Cirrhosis Dysbiosis Ratio (CDR), which reflects the ratio of autochthonous to non-autochthonous bacterial taxa. A lower CDR indicates dysbiosis. The study found that CDR was highest in healthy controls and lowest in cirrhotic patients, with a significant negative correlation with endotoxin levels. In stable cirrhotic patients, the microbiome remained relatively unchanged over time. However, after the development of hepatic encephalopathy (HE), there was a significant decrease in CDR, indicating increased dysbiosis. In patients with infections, the microbiome was significantly different between infected and uninfected cirrhotics, with lower CDR and higher endotoxin levels in infected patients. These changes were associated with higher rates of death, organ failure, and acute-on-chronic liver failure (ACLF). The CDR was also significantly lower in patients who developed ACLF compared to those without. The study concludes that progressive changes in the gut microbiome accompany cirrhosis and become more severe in the setting of decompensation. The CDR may serve as a useful quantitative index to describe microbiome alterations associated with cirrhosis progression. The study highlights the importance of the gut microbiome in cirrhosis and its complications, and suggests that the CDR could be a valuable tool for monitoring disease progression and outcomes.The study investigates changes in the gut microbiome in patients with cirrhosis and its complications. It defines the Cirrhosis Dysbiosis Ratio (CDR), which reflects the ratio of autochthonous to non-autochthonous bacterial taxa. A lower CDR indicates dysbiosis. The study found that CDR was highest in healthy controls and lowest in cirrhotic patients, with a significant negative correlation with endotoxin levels. In stable cirrhotic patients, the microbiome remained relatively unchanged over time. However, after the development of hepatic encephalopathy (HE), there was a significant decrease in CDR, indicating increased dysbiosis. In patients with infections, the microbiome was significantly different between infected and uninfected cirrhotics, with lower CDR and higher endotoxin levels in infected patients. These changes were associated with higher rates of death, organ failure, and acute-on-chronic liver failure (ACLF). The CDR was also significantly lower in patients who developed ACLF compared to those without. The study concludes that progressive changes in the gut microbiome accompany cirrhosis and become more severe in the setting of decompensation. The CDR may serve as a useful quantitative index to describe microbiome alterations associated with cirrhosis progression. The study highlights the importance of the gut microbiome in cirrhosis and its complications, and suggests that the CDR could be a valuable tool for monitoring disease progression and outcomes.