What is the initial management for patients with decompensated liver disease?

Initial Management of Decompensated Liver Disease

The initial management of patients with decompensated liver disease should include immediate treatment with nucleos(t)ide analogues (NAs) with high barrier to resistance for viral hepatitis, sodium restriction, diuretic therapy starting with spironolactone, and assessment for liver transplantation. 1, 2

Assessment and Diagnosis

• Identify the cause of decompensation: viral hepatitis (HBV, HCV), alcoholic hepatitis, or other etiologies
• Evaluate severity using:
  • Child-Pugh score
  • MELD score (Model for End-Stage Liver Disease)
  • Presence of complications: ascites, variceal bleeding, hepatic encephalopathy
• Laboratory tests: liver function, renal function, electrolytes, coagulation profile
• Imaging: ultrasound to assess for ascites, portal hypertension, and hepatocellular carcinoma

Management of Specific Etiologies

Viral Hepatitis

• HBV-related decompensation:

  • Immediately start nucleos(t)ide analogues (NAs) with high barrier to resistance (entecavir 1 mg daily or tenofovir) regardless of HBV DNA level 1
  • PEG-IFN is contraindicated in decompensated cirrhosis 1
  • Monitor for drug tolerability and rare side effects like lactic acidosis or kidney dysfunction 1

• HCV-related decompensation:

  • Direct-acting antivirals (DAAs) without protease inhibitors 1
  • Protease inhibitors (asunaprevir, paritaprevir, grazoprevir, glecaprevir, voxilaprevir) are contraindicated in CTP class B and C 1

Alcoholic Hepatitis with Decompensation

• Immediate alcohol cessation
• Nutritional support: 35-40 kcal/kg/day and 1.2-1.5 g/kg/day protein 2

Management of Ascites

1. Grade 1 (mild, only detectable by ultrasound):

   • Sodium restriction alone (80-120 mmol/day) 2

2. Grade 2 (moderate abdominal distension):

   • Sodium restriction + diuretics 2
   • Start with spironolactone 100 mg/day (can increase to 400 mg/day) 2, 3
   • Add furosemide 40 mg/day (can increase to 160 mg/day) if needed 2
   • Target weight loss: 0.5 kg/day without edema, 1 kg/day with edema 2

3. Grade 3 (large, tense ascites):

   • Initial large volume paracentesis (LVP) + sodium restriction + diuretics 2
   • Administer albumin (8g/L of ascites removed) when removing >5L 2

Management of Other Complications

Spontaneous Bacterial Peritonitis (SBP)

• Diagnose with ascitic fluid neutrophil count >250 cells/μL
• Treat with third-generation cephalosporins (ceftriaxone 1g/24h) for 5-7 days
• Administer albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) 2

Hepatic Encephalopathy

• Identify and treat precipitating factors
• Lactulose titrated to 2-3 soft bowel movements per day
• Consider rifaximin for recurrent episodes

Variceal Bleeding

• Endoscopic therapy (band ligation for esophageal varices)
• Non-selective beta-blockers after initial bleeding control
• Antibiotics prophylaxis during acute bleeding

Liver Transplantation Evaluation

• All patients with decompensated cirrhosis should be referred for liver transplantation evaluation 1
• Patients with early treatment initiation have better clinical outcomes 1
• High baseline Child-Pugh or MELD scores are predictors of poor survival 1
• Improvement in MELD or Child-Pugh score early on-treatment is highly predictive of transplant-free survival 1

Monitoring

• Regular assessment of weight, fluid status, and electrolytes
• Monitor for hepatorenal syndrome, SBP, and hepatic encephalopathy
• Adjust diuretic doses based on response
• Perform clinical assessment every 3-6 months
• Laboratory tests and calculation of CTP and MELD scores every 6 months
• Ultrasound for HCC surveillance every 6 months 2

Important Precautions

• Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers as they can worsen ascites control 2
• Avoid nephrotoxic drugs including aminoglycosides
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 2
• In patients with cirrhosis, initiate spironolactone therapy in a hospital setting and titrate slowly 3
• Monitor renal function closely, especially in elderly patients 3

The management of decompensated liver disease requires a comprehensive approach addressing the underlying cause, complications, and preparation for potential liver transplantation. Early intervention with appropriate antiviral therapy for viral hepatitis and proper management of ascites and other complications can significantly improve outcomes and quality of life.