What is the treatment for decompensated cirrhosis?

Treatment of Decompensated Cirrhosis

The treatment of decompensated cirrhosis requires a comprehensive approach addressing the underlying cause while managing complications such as ascites, variceal bleeding, hepatic encephalopathy, and renal dysfunction to improve morbidity, mortality, and quality of life.

Addressing the Underlying Cause

• Remove the etiological factor whenever possible 1:
  • Complete alcohol abstinence for alcoholic cirrhosis
  • Antiviral therapy for hepatitis B (tenofovir or entecavir) 1, 2
  • Direct-acting antivirals for hepatitis C 2

Management of Ascites

Assessment and Grading

• Diagnostic paracentesis is essential for all patients with new-onset ascites 2
• Ascites is graded as:
  • Grade 1 (mild): Only detectable by ultrasound
  • Grade 2 (moderate): Moderate abdominal distension
  • Grade 3 (large): Marked abdominal distension 1

Treatment Algorithm Based on Severity

1. Grade 1 (Mild) Ascites:

   • Sodium restriction (5-6.5g salt/day) 2

2. Grade 2 (Moderate) Ascites:

   • First episode: Start with spironolactone alone 100 mg/day, can increase up to 400 mg/day 1, 2
   • Recurrent ascites: Combination therapy with spironolactone 100 mg + furosemide 40 mg daily 1, 2, 3, 4
   • Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 1

3. Grade 3 (Large/Tense) Ascites:

   • Large volume paracentesis (LVP) with albumin replacement 1, 2
   • Albumin infusion (8 g/L of ascites removed) for paracentesis >5L 1, 2
   • Follow with diuretic therapy to prevent reaccumulation 1, 5

Diuretic Therapy Considerations

• Monitor for complications: renal failure, hepatic encephalopathy, electrolyte disturbances 1
• Adjust dosing based on response and side effects 1, 6
• In patients with cirrhosis, initiate therapy in hospital setting and titrate slowly 3
• Discontinue diuretics if serum sodium <120-125 mmol/L 1

Management of Variceal Bleeding

• Acute variceal hemorrhage (AVH) requires:
  • Volume resuscitation with restrictive transfusion strategy (hemoglobin threshold 7 g/dl) 1
  • Vasoactive drugs (terlipressin, somatostatin, octreotide) 1
  • Endoscopic band ligation (EBL) within 12 hours 1
  • Prophylactic antibiotics (ceftriaxone 1g/24h) 1

Prevention of Spontaneous Bacterial Peritonitis (SBP)

• Antibiotic prophylaxis for high-risk patients:
  • History of SBP: norfloxacin 400 mg daily or ciprofloxacin 500 mg daily 1, 2
  • Ascitic fluid protein <1.5 g/dL with advanced liver failure or renal dysfunction 2

Management of Hepatic Encephalopathy

• Lactulose as first-line therapy 2, 7
• Rifaximin for recurrent episodes 2
• Avoid sedatives and medications that may precipitate encephalopathy 1

Renal Protection Strategies

• Avoid nephrotoxic drugs:
  • NSAIDs 1, 2, 8
  • Aminoglycosides 1, 8
  • Angiotensin-converting enzyme inhibitors 1
  • Angiotensin II receptor antagonists 1
  • α1-adrenergic blockers 1

Nutritional Support

• Caloric intake: 35-40 kcal/kg/day 2
• Protein intake: 1.2-1.5 g/kg/day (no protein restriction) 2
• Consider branched-chain amino acids supplementation 2

Surveillance and Monitoring

• Regular monitoring of liver function, electrolytes, and renal function 2
• Ultrasound screening for hepatocellular carcinoma every 6 months 2, 9
• Endoscopic surveillance for varices every 1-3 years 2

Liver Transplantation

• Consider referral for liver transplantation in patients with:
  • Refractory ascites 1, 2
  • Recurrent variceal bleeding 1
  • Hepatorenal syndrome 1, 7
  • Hepatic encephalopathy 1

Common Pitfalls and Caveats

1. Diuretic therapy:

   • Avoid rapid fluid removal which can precipitate hepatorenal syndrome
   • Monitor for hyponatremia, hypo/hyperkalemia, and renal dysfunction
   • Spironolactone alone may be preferable for first episodes of ascites 6

2. Medication cautions:

   • NSAIDs can cause renal failure, hyponatremia, and diuretic resistance 1, 8
   • Beta-blockers may need dose reduction or discontinuation during active bleeding or renal dysfunction

3. Paracentesis:

   • Always administer albumin after large volume paracentesis to prevent post-paracentesis circulatory dysfunction 1, 5
   • Routine correction of coagulopathy before paracentesis is not necessary 2

4. Transplantation timing:

   • Early referral for transplant evaluation is critical as waiting times can be lengthy 2

Decompensated cirrhosis requires close monitoring and prompt management of complications to improve outcomes while pursuing definitive treatment through transplantation when appropriate.