What is the treatment for acute decompensated cirrhosis?

From the Guidelines

The treatment for acute decompensated cirrhosis should focus on managing complications with vasoactive drugs and intravenous albumin, as recommended in the latest clinical practice update 1. The management of acute decompensated cirrhosis involves a multifaceted approach to address the underlying cause and manage complications.

• Initial management includes fluid restriction, diuretics, and sodium restriction.
• For patients with ascites, large-volume paracentesis may be performed with albumin replacement, as intravenous albumin increases effective arterial blood volume and is used in the prevention of acute kidney injury (AKI) and death after large-volume paracentesis 1.
• Hepatic encephalopathy requires lactulose and rifaximin, while variceal bleeding necessitates octreotide, prophylactic antibiotics, and urgent endoscopy for band ligation.
• Spontaneous bacterial peritonitis requires antibiotics, and hepatorenal syndrome is treated with albumin plus vasoconstrictors like terlipressin, which was recently approved by the US Food and Drug Administration 1.
• The combination of vasoconstrictors and albumin is used in the reversal of hepatorenal syndrome (HRS-AKI), the most lethal complication of cirrhosis, and should be prioritized in the treatment of acute decompensated cirrhosis 1. Key considerations in the treatment of acute decompensated cirrhosis include:
• Addressing the underlying cause, whether it's alcohol cessation, antiviral therapy for hepatitis, or other specific treatments.
• Liver transplantation evaluation should be initiated promptly as it represents the definitive treatment for eligible patients with end-stage liver disease.
• The use of vasoactive drugs and intravenous albumin should be guided by the latest clinical practice update, which recommends their use in specific scenarios such as variceal hemorrhage, ascites and spontaneous bacterial peritonitis, and hepatorenal syndrome 1.

From the FDA Drug Label

The efficacy of TERLIVAZ was assessed in a multicenter, double-blind, randomized, placebo-controlled study (CONFIRM) TERLIVAZ is indicated to improve kidney function in adults with hepatorenal syndrome with rapid reduction in kidney function. Patients received 1 mg terlipressin acetate (equivalent to TERLIVAZ 0. 85 mg) or placebo every 6 hours administered as an IV bolus injection over 2 minutes for a maximum of 14 days.

The treatment for acute decompensated cirrhosis involves the use of terlipressin (IV), with a recommended starting dosage of 0.85 mg every 6 hours by slow intravenous bolus injection. The dose may be adjusted based on changes from baseline serum creatinine (SCr) using a dosing chart. It is essential to monitor patient oxygen saturation using continuous pulse oximetry and assess Acute-on-Chronic Liver Failure (ACLF) Grade and volume status before initiating treatment 2, 2, 2.

From the Research

Treatment Overview

The treatment for acute decompensated cirrhosis typically involves addressing the underlying cause of decompensation, such as infections, gastrointestinal bleeding, or high alcohol intake, as well as managing the associated complications like ascites, hepatic encephalopathy, and hepatorenal syndrome 3, 4, 5.

Management of Complications

• Ascites: Emerging evidence suggests that transjugular intrahepatic portosystemic shunt (TIPS) might be used earlier in patients with ascites, before strict criteria for refractory ascites are met 4. Long-term albumin use is also being assessed for improving the prognosis of patients with uncomplicated ascites 6.
• Hepatic Encephalopathy: Lactulose and rifaximin are first- and second-line treatments for hepatic encephalopathy, respectively 4. Newer therapies such as L-ornithine L-aspartate and albumin require further assessment.
• Hepatorenal Syndrome: First-line treatment is the combination of terlipressin and albumin 4.
• Gastrointestinal Bleeding: Pre-emptive TIPS improves mortality rate in patients with acute variceal hemorrhage at high risk of failure with standard treatment 4. Retrograde transvenous obliteration and/or variceal cyanoacrylate injection are alternatives to TIPS for bleeding from gastrofundal varices.

Role of Albumin

Albumin administration has been evaluated in the prevention and management of decompensating events in cirrhosis, including large-volume paracentesis, spontaneous bacterial peritonitis, acute kidney injury, and hepatorenal syndrome 6. Further studies are necessary to elucidate its benefits in patients with other complications.

Importance of Early Intervention

Rapid identification and treatment of the triggering event of decompensation, as well as specific measures for the treatment of concomitant extrahepatic organ dysfunctions, are essential to improve the patient's prognosis and prevent the development of acute-on-chronic liver failure (ACLF) 5, 7.