From the Guidelines
Decompensated liver cirrhosis has a poor prognosis with 1-year mortality rates of 20-50% without liver transplantation, and management should focus on treating complications, evaluating for transplantation, and improving quality of life. The prognosis of decompensated liver cirrhosis is influenced by various factors, including the severity of liver disease, presence of complications, and response to treatment 1.
Management of Decompensated Liver Cirrhosis
Management of decompensated liver cirrhosis involves treating complications such as:
- Ascites: managed with sodium restriction (2000mg/day), fluid restriction if sodium <125mmol/L, and diuretics (starting with spironolactone 100mg daily, adding furosemide 40mg daily if needed) 2
- Hepatic encephalopathy: requires lactulose (30ml every 6 hours initially, titrated to 2-3 soft bowel movements daily) and rifaximin (550mg twice daily) for recurrent episodes 2
- Variceal bleeding: necessitates urgent endoscopy, vasoactive drugs (octreotide 50mcg bolus followed by 50mcg/hour for 3-5 days), and prophylactic antibiotics (ceftriaxone 1g daily for 7 days) 3
- Spontaneous bacterial peritonitis: requires antibiotics (cefotaxime 2g every 8 hours or ceftriaxone 1g daily for 5-7 days) and albumin (1.5g/kg on day 1, 1g/kg on day 3) 1
- Hepatorenal syndrome: treated with vasoconstrictors (terlipressin 0.5-2mg every 4-6 hours) plus albumin (20-40g/day) 3
Evaluation for Liver Transplantation
Patients with decompensated liver cirrhosis should be evaluated for liver transplantation early, as it offers the only definitive treatment 2.
Supportive Measures
Essential supportive measures include:
- Abstinence from alcohol
- Vaccination against hepatitis A and B
- Nutritional support (1.2-1.5g/kg protein daily)
- Regular monitoring of liver function, renal function, electrolytes, and screening for hepatocellular carcinoma every 6 months with ultrasound 1
Quality of Life
Improving quality of life is a crucial aspect of managing decompensated liver cirrhosis, and can be achieved through a multidisciplinary approach, including care coordination programs, educational programs for patients and caregivers, and optimization of treatment plans 2.
From the Research
Prognosis of Decompensated Liver Cirrhosis
- The prognosis of decompensated liver cirrhosis is generally poor, with a high mortality rate 4, 5, 6.
- The Model for End-Stage Liver Disease (MELD) score is a useful tool for predicting mortality in patients with decompensated liver cirrhosis, with a sensitivity of 72.2% and positive predictive value of 93.6% for 1-month mortality 6.
- The mortality risk varies greatly between different subgroups of decompensated cirrhosis, with acute-on-chronic liver failure (ACLF) being the most severe form and having a high short-term mortality 4.
Management of Decompensated Liver Cirrhosis
- The management of decompensated liver cirrhosis involves treating the underlying complications such as ascites, variceal hemorrhage, and hepatic encephalopathy 7.
- Non-selective β-blockers can prevent decompensation in patients with clinically significant portal hypertension, and may reduce the risk of ascites and other complications 5, 7.
- Transjugular intrahepatic portosystemic shunt (TIPS) may be used to treat refractory ascites and other complications, and may improve mortality rates in certain patients 7, 8.
- The use of aldosterone antagonists and loop diuretics may increase the resolution of ascites, but may also increase the risk of other decompensation events such as hepatic encephalopathy and variceal bleeding 8.
Predictive Scoring Systems
- The MELD score is a widely used predictive scoring system for mortality in patients with decompensated liver cirrhosis, and has been shown to be a good predictor of 1-month mortality 6.
- Other predictive scoring systems, such as the Child-Pugh score, may also be used to assess the prognosis of patients with decompensated liver cirrhosis 7.
- Emerging predictive scoring systems and non-invasive measurement methods may allow for earlier identification of patients at risk of severe complications and improve outcomes 4.