What is the management plan for a patient with chronic liver dysfunction?

Management of Chronic Liver Dysfunction

The management of chronic liver dysfunction requires a systematic approach focused on identifying the underlying cause, preventing disease progression, and treating complications to reduce morbidity and mortality.

Assessment and Diagnosis

• Evaluate disease severity: Use specialized prognostic scores that account for hepatic and extrahepatic organ failures (NACSELD, CLIF-C, or AARC ACLF scores) rather than conventional scores like MELD or MELD-Na 1

• Laboratory workup:

  • Complete blood count, comprehensive metabolic panel
  • Liver function tests (ALT, AST, ALP, GGT, bilirubin)
  • Coagulation studies (PT/INR, factor V)
  • Serum ammonia levels
  • Blood glucose and lactate levels 1

• Imaging:

  • Hepatic Doppler ultrasound to assess liver structure and blood flow
  • Transient elastography (FibroScan) to evaluate liver stiffness (≥15 kPa highly suggestive of advanced chronic liver disease) 1
  • Avoid unnecessary imaging if infection control is a concern 1

• Screen for common etiologies:

  • Viral hepatitis (HBV, HCV)
  • Alcohol-related liver disease
  • Metabolic syndrome and non-alcoholic fatty liver disease
  • Autoimmune liver diseases
  • Hereditary disorders (hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency) 1

Management Strategy

1. Treat the Underlying Cause

• Viral hepatitis:

  • For HBV: Consider entecavir (0.5 mg daily for treatment-naïve patients with compensated liver disease; 1 mg daily for decompensated liver disease) 2
  • For HCV: Refer to hepatologist for antiviral therapy 1

• Alcohol-related liver disease:

  • Complete alcohol cessation is essential 3
  • Consider addiction counseling and support groups

• Metabolic-associated fatty liver disease:

  • Weight loss through diet and exercise
  • Management of diabetes, hypertension, and dyslipidemia

2. Prevent Disease Progression

• Serial monitoring:

  • Regular assessment of liver function tests
  • Periodic calculation of prognostic scores to track disease progression 1
  • Monitor for development of complications

• Post-viral hepatitis monitoring:

  • Continue hepatological follow-up despite successful antiviral therapy
  • Screen for additional factors of chronic liver damage 1

3. Manage Complications

Hepatic Encephalopathy (HE)

• For altered mental status:

  • Protect airway to prevent aspiration
  • Transfer to monitored setting if necessary
  • Investigate cause of altered mental status
  • Determine and treat precipitating factors
  • Provide empiric therapy for suspected HE 1

• Treatment:

  • Lactulose (reduces risk of recurrent overt HE and mortality) 3
  • Rifaximin (especially for recurrent HE)
  • Avoid sedating medications when possible 1

Portal Hypertension and Related Complications

• Ascites management:

  • Sodium restriction
  • Combination of aldosterone antagonist and loop diuretics
  • Large-volume paracentesis with albumin for refractory ascites 3

• Variceal bleeding prevention:

  • Nonselective β-blockers (carvedilol or propranolol) 3
  • Endoscopic surveillance and therapy as indicated

• Spontaneous bacterial peritonitis (SBP):

  • Prophylactic antibiotics for high-risk patients
  • Prompt treatment when diagnosed

Hepatorenal Syndrome

• Management:
  • Terlipressin improves reversal rates 3
  • Albumin administration
  • Avoid nephrotoxic medications

Bone Disease

• Prevention and treatment:
  • Calcium supplements (1,000-1,500 mg/day)
  • Vitamin D supplements (400-800 IU/day)
  • Consider bisphosphonates for patients with osteoporosis 1

4. Consider Liver Transplantation

• Early referral for transplant evaluation in appropriate candidates
• Particularly important for patients with:
  • Decompensated cirrhosis
  • Acute-on-chronic liver failure
  • Hepatocellular carcinoma 3

Monitoring and Follow-up

• Regular surveillance:

  • Hepatocellular carcinoma screening (ultrasound ± alpha-fetoprotein every 6 months)
  • Endoscopic surveillance for varices
  • Bone densitometry every 2-3 years (or yearly in high-risk patients) 1

• Quality of life assessment:

  • Evaluate and treat common symptoms like muscle cramps, pruritus, sleep disturbances, and sexual dysfunction 4

Prognosis

The development of decompensation significantly worsens prognosis, with median survival decreasing from >12 years in compensated cirrhosis to approximately 2 years after decompensation. Progression to acute-on-chronic liver failure further increases mortality risk 3.

Important Considerations

• Medication management: Avoid unnecessary medications and adjust dosages for hepatic impairment
• Infection prevention: Patients with chronic liver dysfunction are immunocompromised and at higher risk for infections
• Nutritional support: Maintain adequate protein intake unless severe encephalopathy is present
• Patient education: Educate patients about medication effects, early signs of complications, and when to seek medical attention 1