What labs should be checked daily for an inpatient with cirrhosis?

Daily Laboratory Monitoring for Hospitalized Patients with Cirrhosis

For hospitalized patients with cirrhosis, daily laboratory tests should include complete blood count, comprehensive metabolic panel (including liver function tests), and coagulation studies (PT/INR) to monitor disease progression and prevent complications. 1

Core Daily Laboratory Tests

Essential Daily Labs

• Complete Blood Count (CBC) 1, 2

  • Monitors for anemia, thrombocytopenia, and infection
  • Low platelets may indicate worsening portal hypertension
  • White blood cell count helps detect infections early

• Comprehensive Metabolic Panel 1, 2

  • Electrolytes (sodium, potassium)
  • Renal function (BUN, creatinine)
  • Liver function tests:
    • Bilirubin (total and direct)
    • Albumin
    • AST/ALT
    • Alkaline phosphatase

• Coagulation Studies 1, 2

  • PT/INR
  • Note: While INR has limitations in predicting bleeding risk in cirrhosis, it remains important for monitoring disease severity and calculating MELD scores

Additional Tests Based on Clinical Context

• D-dimer and Fibrinogen 1

  • Particularly important within first 24 hours of hospitalization
  • May improve prediction of 90-day mortality over MELD score alone
  • Helps distinguish disseminated intravascular coagulation (DIC) from cirrhotic coagulopathy

• For Patients with Ascites 1

  • Monitor electrolytes more closely if on diuretics
  • Consider spot urine sodium/potassium ratio to guide diuretic therapy

Frequency of Monitoring

The AASLD Practice Guidance recommends daily laboratory monitoring for hospitalized patients with cirrhosis, particularly those with acute-on-chronic liver failure or critical illness 1. This is essential for:

1. Early detection of complications
2. Guiding therapeutic interventions
3. Assessing response to treatments
4. Calculating and updating prognostic scores (MELD, Child-Pugh)

Important Considerations

• Avoid Overreliance on INR for Bleeding Risk: Traditional coagulation tests (PT/INR) have significant limitations in cirrhosis as they only partially evaluate hemostasis and neglect counterbalanced factors 2, 1

• Viscoelastic Testing: Consider thromboelastography (TEG) or rotational thromboelastometry (ROTEM) for more comprehensive assessment of hemostasis, especially in patients with bleeding concerns or before procedures 1, 2

• Monitoring Diuretic Response: For patients on diuretics for ascites, daily weight measurements and electrolyte monitoring are crucial to prevent complications like hyponatremia and renal dysfunction 1

• Surveillance Gaps: Research shows that laboratory monitoring for cirrhosis patients is often suboptimal, with less than 30% of patients receiving recommended monitoring frequency 3

Special Circumstances

• Acute Kidney Injury: More frequent monitoring of renal function may be needed
• Hepatic Encephalopathy: Monitor ammonia levels (though clinical assessment remains primary)
• Spontaneous Bacterial Peritonitis: Repeat paracentesis with cell count after 48 hours of antibiotics to document response 1

Daily laboratory monitoring is a cornerstone of inpatient cirrhosis management, allowing for early detection of complications and timely interventions that can significantly impact morbidity and mortality outcomes.