From the Guidelines
The management of a patient with severe liver disease requires a comprehensive approach addressing multiple aspects of care, with the primary goal of improving morbidity, mortality, and quality of life, as outlined in the most recent guidelines by Nanchal et al 1.
Key Components of Management
- Identifying and treating the underlying cause of liver disease, such as stopping alcohol consumption in alcoholic liver disease, antiviral therapy for viral hepatitis, or weight loss in non-alcoholic fatty liver disease.
- Nutritional support with 35-40 kcal/kg/day and 1.2-1.5 g/kg/day of protein to prevent muscle wasting.
- Active management of complications:
- Ascites: sodium restriction (2000 mg/day) and diuretics (starting with spironolactone 100 mg daily, adding furosemide 40 mg daily if needed), with large-volume paracentesis for refractory cases.
- Hepatic encephalopathy: lactulose (30 ml orally 2-4 times daily, titrated to 2-3 soft bowel movements daily) and rifaximin (550 mg twice daily) for prevention of recurrence.
- Variceal bleeding: prophylactic non-selective beta-blockers (propranolol 20-40 mg twice daily or nadolol 20-40 mg daily) for patients with large varices, while acute bleeding requires vasoactive drugs (octreotide 50 mcg IV bolus followed by 50 mcg/hour infusion), endoscopic band ligation, and prophylactic antibiotics (ceftriaxone 1 g daily for 5-7 days).
- Hepatorenal syndrome: treated with albumin and vasoconstrictors like norepinephrine (0.5-3 mg/hour) or terlipressin (1-2 mg every 4-6 hours).
Liver Transplantation
For end-stage liver disease, timely referral for liver transplantation evaluation is essential, as it remains the definitive treatment for suitable candidates, with recent guidelines emphasizing the importance of early evaluation and listing for transplantation 1.
Recent Guidelines and Recommendations
The most recent guidelines by Nanchal et al 1 and the EASL clinical practice guidelines on liver transplantation 1 provide evidence-based recommendations for the management of patients with severe liver disease, emphasizing the importance of a comprehensive approach and timely referral for liver transplantation evaluation.
From the Research
Management Approach for Severe Liver Disease
- The management of severe liver disease involves correcting coagulopathy, which can be achieved through various therapies, including vitamin K replacement, transfusion of fresh frozen plasma, and cryoprecipitate 2, 3.
- In patients with acute liver failure, the cause of liver failure affects the management and prognosis, and extensive investigation for cause is strongly suggested 4.
- Liver transplantation is the best current therapy for acute liver failure, although artificial liver support systems, such as therapeutic plasma exchange, can be useful in non-transplant centers 4.
- The management of coagulopathy in liver disease involves gaining hemostasis, rather than achieving complete correction of laboratory value abnormalities 3.
- Therapy with prothrombin-complex concentrate is seldom pursued in patients with liver disease due to the high risk of thrombotic complications 3.
- Transfusions of platelets are appropriate for patients with thrombocytopenia associated with active bleeding or before invasive procedures 2, 3.
- Recombinant activated factor VIIa administration is suggested for patients with significantly prolonged prothrombin time and contraindications to fresh frozen plasma therapy 3.
- Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU have been developed, which include recommendations for cardiovascular, endocrine, hematologic, pulmonary, and renal considerations 5.
- The management of acute liver failure requires individualization of care, considering the variety of clinical presentations 6.