What are the management strategies for liver disease?

Management Strategies for Liver Disease

The management of liver disease requires a targeted approach based on the specific etiology, with treatment focusing on the underlying cause, preventing disease progression, and managing complications to reduce morbidity and mortality.

Diagnostic Approach

• Initial assessment should include:
  • Complete blood aetiology screen to identify underlying causes 1
  • Detailed alcohol history using standardized tools (e.g., AUDIT-C) 1
  • Drug history to identify medication-induced liver disease 1
  • Non-invasive fibrosis assessment using:
    • Blood-based scores (e.g., FIB-4, APRI) 1
    • Imaging techniques (transient elastography) 1

Management Based on Etiology

Cholestatic Liver Disease

• Primary Biliary Cirrhosis (PBC):
  • First-line: Ursodeoxycholic acid 1
  • Second-line: Consider obeticholic acid for incomplete response 1
  • Monitor for complications of portal hypertension 1

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD/NAFLD)

• Lifestyle modifications:
  • Weight loss of 3-5% to improve steatosis 1
  • Weight loss of 7-10% to improve necroinflammation 1
  • Regular physical exercise 1
• Pharmacological therapy:
  • For patients with type 2 diabetes or obesity: Incretin-based therapies (semaglutide, tirzepatide) 1
  • For non-cirrhotic MASH with significant fibrosis: Consider resmetirom 1
  • Metformin may improve aminotransferases but has limited histological benefit 1
• Bariatric surgery for patients with obesity 1

Viral Hepatitis

• Chronic Hepatitis B:
  • Entecavir 0.5 mg daily for treatment-naïve patients 2
  • Entecavir 1 mg daily for lamivudine-resistant cases or decompensated liver disease 2
  • Dose adjustment required for renal impairment 2
  • Monitor for severe acute exacerbations upon discontinuation 2

Management of Complications

Portal Hypertension

• Screen all patients with advanced chronic liver disease for clinically significant portal hypertension 1
• Manage variceal bleeding with:
  • Prophylactic antibiotics (ceftriaxone 1g/24h) 3
  • Restrictive transfusion strategy (hemoglobin threshold 7 g/dl) 3
  • Vasoactive drugs (terlipressin, somatostatin, octreotide) 3
  • Endoscopic band ligation within 12 hours 3
  • Non-selective beta-blockers for prophylaxis 3

Ascites

• Treatment based on ascites grade:
  • Grade 1 (mild): Sodium restriction 3
  • Grade 2 (moderate): Sodium restriction + diuretics (spironolactone 100 mg/day, can increase up to 400 mg/day) 3
  • Grade 3 (large): Sodium restriction + diuretics + large volume paracentesis with albumin replacement 3
• Long-term albumin administration (25g/week up to 1 year, then 25g every 2 weeks) after first-onset ascites 3

Hepatic Encephalopathy

• First-line therapy: Lactulose 1
• Second-line: Rifaximin 1
• Avoid sedatives and medications that may precipitate encephalopathy 3
• Consider branched-chain amino acid supplementation 3

Hepatocellular Carcinoma (HCC)

• Surveillance with ultrasound ± serum alpha-fetoprotein every 6 months in patients with advanced fibrosis or cirrhosis 1
• Treatment options based on BCLC staging:
  • Very early/early stage (0-A): Resection, transplantation, or ablation 1
  • Intermediate stage (B): Transarterial chemoembolization 1
  • Advanced stage (C): Systemic therapy 1

Nutritional Management

• Adequate caloric intake (35-40 kcal/kg/day) 3
• Protein intake (1.2-1.5 g/kg/day) 3
• Sodium restriction (5-6.5 g salt/day) 3
• Avoid nephrotoxic drugs (NSAIDs, aminoglycosides, ACE inhibitors) 3

Liver Transplantation

• Consider referral for evaluation in patients with:
  • Decompensated cirrhosis 3, 4
  • Refractory ascites 3
  • Recurrent variceal bleeding 3
  • Hepatorenal syndrome 3
  • Hepatic encephalopathy 3
  • Hepatocellular carcinoma within transplant criteria 1

Emerging Therapies

• Antioxidant and anti-inflammatory agents 5
• Anti-hepatic stellate cell therapies for fibrosis 5
• Gene therapy and cell-based approaches 5
• Gut microbiota modulation 5

Monitoring and Follow-up

• Reassess fibrosis using non-invasive tests every 3 years in patients with NAFLD at low risk 1
• More frequent monitoring (1-3 years) for those with risk factors for fibrosis progression 1
• Monitor hepatic function with both clinical and laboratory follow-up for at least several months in patients who discontinue anti-hepatitis B therapy 2

Pitfalls and Caveats

• Liver biopsy remains the most reliable technique for diagnosis and staging when multiple risk factors are present 1
• Avoid abrupt discontinuation of antiviral therapy due to risk of severe acute exacerbations 2
• Be vigilant for lactic acidosis and severe hepatomegaly with steatosis in patients on nucleoside analogue inhibitors 2
• Recognize that occupational liver disease may require removal from exposure to suspected toxins 1