Why do patients with Chronic Liver Disease (CLD) require regular follow-ups?

Why Patients with Chronic Liver Disease Need Regular Follow-ups

Patients with chronic liver disease (CLD) require regular follow-ups primarily to monitor for disease progression, detect complications early, screen for hepatocellular carcinoma, and adjust management strategies accordingly to reduce morbidity and mortality. 1

Key Reasons for Regular Follow-up

1. Disease Progression Monitoring

• Fibrosis progression assessment:
  • Annual non-invasive fibrosis assessment using transient elastography (FibroScan) or serum biomarkers (FIB-4, ELF test) 2
  • Increase in liver stiffness measurement (LSM) >1.5 kPa/year indicates disease progression 2
  • Regular monitoring allows for early intervention before irreversible damage occurs

2. Detection of Portal Hypertension

• Screening for clinically significant portal hypertension (CSPH):
  • CSPH significantly increases risk of decompensation events and HCC 1
  • Post-treatment LSM <12 kPa and platelet count >150 G/L rule out CSPH 1
  • Regular assessment of platelet count, bilirubin, and albumin every 6-12 months 1

3. Hepatocellular Carcinoma (HCC) Surveillance

• Mandatory 6-month ultrasound screening:
  • All patients with advanced fibrosis (F3) or cirrhosis require ultrasound every 6 months 1, 2
  • Early detection of HCC significantly improves survival outcomes
  • This surveillance must continue indefinitely, even after achieving viral clearance in cases of viral hepatitis 1

4. Monitoring for Decompensation Events

• Early detection of:
  • Ascites
  • Variceal bleeding
  • Hepatic encephalopathy
  • Spontaneous bacterial peritonitis
  • Jaundice
• These events significantly increase mortality risk and require prompt intervention 1

Follow-up Schedule Based on Disease Stage

For Patients with Minimal/No Fibrosis

• VCTE-LSM <8 kPa or FIB-4 <1.45:
  • Follow-up by general practitioner
  • Repeat non-invasive testing annually or every 2-3 years
  • Focus on lifestyle modifications and addressing risk factors 1, 2

For Patients with Intermediate Risk

• VCTE-LSM 8-12 kPa or FIB-4 1.45-3.25:
  • More frequent monitoring (every 6-12 months)
  • Assessment of comorbidities (alcohol intake, metabolic dysfunction-associated steatotic liver disease)
  • Referral to hepatologist if comorbidities present 1, 2

For Patients with Advanced Fibrosis/Cirrhosis

• VCTE-LSM >12 kPa or FIB-4 >3.25:
  • Follow-up by liver disease specialist regardless of comorbidities
  • Laboratory testing every 6 months (including platelet count, bilirubin, albumin)
  • Ultrasound for HCC screening every 6 months
  • Endoscopic screening for varices based on risk stratification 1, 2

Specific Monitoring Parameters

Laboratory Tests

• Liver function tests (ALT, AST, GGT, ALP, bilirubin)
• Platelet count (marker for portal hypertension)
• Albumin and prothrombin time (synthetic function)
• Specific viral markers in viral hepatitis (HBV DNA, HDV RNA, HCV RNA) 1

Imaging Studies

• Ultrasound every 6 months for HCC surveillance and signs of portal hypertension
• Elastography (FibroScan) annually to assess fibrosis progression
• MRI/MRCP in specific etiologies like PSC 1, 2

Endoscopic Evaluation

• Based on risk stratification:
  • Post-treatment LSM <20 kPa and platelets >150 G/L: high-risk varices ruled out
  • Post-treatment LSM >20 kPa or platelets <150 G/L: endoscopy recommended 1

Common Pitfalls to Avoid

1. Discharging patients after viral clearance: Even after achieving SVR in hepatitis C, patients with advanced fibrosis still require HCC surveillance 1

2. Using standard reference values for liver enzymes in patients on dialysis: Lower "normal" values should be adopted for dialysis patients 3

3. Overlooking comorbidities: Factors like alcohol intake, obesity, and metabolic syndrome can accelerate disease progression even after treating the primary liver disease 1, 2

4. Inadequate screening intervals: Extending HCC screening beyond 6 months significantly reduces the chance of detecting early-stage, treatable tumors 1

5. Missing early signs of decompensation: Subtle changes in laboratory parameters or new symptoms require prompt evaluation 2

Regular follow-up of CLD patients is essential for early detection of complications and timely intervention, which ultimately improves survival and quality of life.