Guidelines for Managing Chronic Liver Disease
The management of chronic liver disease requires a comprehensive approach focusing on disease-specific interventions, nutritional support, and prevention of complications to reduce morbidity and mortality.
Diagnosis and Assessment
- Chronic liver disease is defined as cirrhosis (clinically or histologically proven) or severe cholestasis (bilirubin more than three times the upper limit of normal for more than six months) 1
- Assess nutritional status using validated tools like the Royal Free Hospital Nutritional Prioritizing Tool (RFH-NPT) 1
- Evaluate for sarcopenia, which is associated with worse outcomes 1
- Perform bone densitometry (DXA) in patients with:
- Previous fragility fractures
- Those treated with corticosteroids
- Patients awaiting liver transplantation
- Cholestatic diseases
- Cirrhosis 1
Nutritional Management
Dietary Recommendations
- Provide adequate protein intake:
- 1.2 g/kg/day for compensated cirrhosis
- 1.5 g/kg/day for malnourished patients 2
- Implement small, frequent meals with a late-evening snack to prevent catabolism 1
- Ensure adequate caloric intake (35 kcal/kg/day) 1
- Supplement with calcium (1,000-1,500 mg/day) and vitamin D (400-800 IU/day) 1
- Avoid raw or undercooked seafood due to risk of bacterial infections 2
- Recommend a Mediterranean-style diet rich in vegetables, whole grains, fruits, and cooked seafood 2
Specific Dietary Restrictions
- Reduce alcohol intake if excessive 1
- Limit salt intake in patients with ascites 1
- Avoid anabolic steroids as they can cause abnormal liver biochemistry 1
Management of Complications
Osteoporosis Management
- Screen for osteoporosis with DXA scan of lumbar spine and femoral neck 1
- Perform lateral X-rays of dorsal and lumbar spine to detect vertebral fractures 1
- For patients with T-score <-2.5 or fragility fractures:
Hepatic Encephalopathy (HE) Management
- Identify and address precipitating factors (infection, GI bleeding, diuretics, constipation) 1
- Ensure adequate nutrition with sufficient protein (do not restrict protein) 1
- Educate patients and relatives about medication effects, importance of adherence, and early signs of recurring HE 1
- Monitor neurological manifestations to adjust treatment 1
Disease-Specific Management
Non-alcoholic Fatty Liver Disease (NAFLD)
- Weight loss of 5-7% has been associated with resolution of NASH 3
- Greater weight loss (≥10%) may improve hepatic fibrosis 3
- Combine diet with exercise to improve histologic components of NAFLD 3
Viral Hepatitis
- For chronic hepatitis B with decompensated liver disease, entecavir 1 mg once daily is recommended 4
- Adjust dosage in patients with renal impairment 4
- Monitor hepatic function closely after discontinuation of anti-hepatitis B therapy 4
Alcoholic Liver Disease
- Complete abstinence from alcohol is essential 1
- Provide nutritional support with adequate protein and calories 1
Follow-up and Monitoring
- Monitor nutritional parameters every 1-6 months depending on cirrhosis severity 2
- Repeat bone densitometry every 2-3 years for normal BMD, or annually in high-risk patients 1
- Assess for complications of cirrhosis (varices, hepatocellular carcinoma) 5
- Consider expedited assessment for liver transplantation in patients with acute-on-chronic liver failure grade 3 6
Prevention Strategies
- Regular weight-bearing exercise 1
- Smoking cessation 1
- Hepatitis vaccination 5
- Avoidance of NSAIDs 5
- Screening for hepatocellular cancer with alpha-fetoprotein testing and ultrasound in cirrhotic patients 5
- Screening for varices by endoscopy in cirrhotic patients 5
The management of chronic liver disease requires a multidisciplinary approach with regular monitoring and adjustment of interventions based on disease progression and the development of complications. Early identification and management of nutritional deficiencies and complications like osteoporosis and hepatic encephalopathy are crucial for improving quality of life and reducing mortality in these patients.