What is the treatment for cirrhosis?

Treatment of Cirrhosis

The treatment of cirrhosis requires a comprehensive approach targeting the underlying cause, preventing disease progression, and managing complications, with antiviral treatment strongly recommended for compensated cirrhosis patients unless absolutely contraindicated. 1

General Management Principles

• Treating the underlying disease is crucial for patients with cirrhotic ascites and should be the first priority 1
• Abstinence from alcohol is essential for patients with alcohol-related cirrhosis, as it can result in dramatic improvement in the reversible component of alcoholic liver disease within months 1
• Patients with cirrhosis should receive regular monitoring with laboratory tests and calculation of Child-Pugh and MELD scores every 6 months 2
• Continuous monitoring for complications is needed even after successful treatment of the underlying cause, as the risk of hepatocellular carcinoma remains in patients with cirrhosis 1

Management Based on Cirrhosis Stage

Compensated Cirrhosis

• Antiviral treatment is strongly recommended for patients with Child-Turcotte-Pugh (CTP) class A cirrhosis to decrease the risk of progression to decompensated cirrhosis and development of hepatocellular carcinoma 1
• For patients with HBV-related compensated cirrhosis, monotherapy with tenofovir or entecavir is recommended due to their potency and minimal risk of resistance 1
• Peginterferon alfa can be used for treating well-compensated cirrhosis in appropriate patients 1
• Nonselective β-blockers (carvedilol or propranolol) should be used to reduce the risk of decompensation or death in patients with portal hypertension 3

Decompensated Cirrhosis

• For patients with decompensated cirrhosis due to HBV, entecavir and tenofovir monotherapy are the preferred first-line options 1
• Peginterferon alfa is contraindicated in patients with decompensated cirrhosis 1
• Patients with CTP class B cirrhosis can be treated with antiviral therapy by experienced specialists with careful monitoring 1
• The current standard treatment regimen is contraindicated in patients with CTP class C due to the high risk of severe complications 1

Management of Complications

Ascites

• Dietary sodium restriction (≤5 g/day or sodium 2 g/day, 88 mmol/day) is recommended 1
• Protein supplementation (1.2-1.5 g/kg/day) is recommended for patients with cirrhotic ascites 1
• The primary diuretic for cirrhotic ascites is an aldosterone antagonist (spironolactone), starting at 50-100 mg/day and increasing up to 400 mg/day 1
• Furosemide can be used in combination with spironolactone, starting at 20-40 mg/day and increasing up to 160 mg/day 1
• Combination aldosterone antagonist and loop diuretics are more effective than sequential initiation (76% vs 56% resolution of ascites) 3
• For large-volume paracentesis, 6-8 g of albumin infusion per liter of ascites drained is recommended 1

Variceal Bleeding

• Vasoactive drug therapy (terlipressin, somatostatin, or octreotide) should be initiated as soon as acute variceal bleeding is suspected, before endoscopy 1
• Gastroscopy should be performed within 12 hours after admission once hemodynamic stability is achieved 1
• Antibiotic prophylaxis is recommended in cirrhotic patients with acute GI bleeding (ceftriaxone 1 g/24h for up to seven days) 1
• Transjugular intrahepatic portosystemic shunt (TIPS) should be used as rescue therapy for uncontrolled bleeding 1

Hepatic Encephalopathy

• Lactulose is the first-line treatment, which has been associated with reduced mortality compared to placebo (8.5% vs 14%) 3, 4
• Rifaximin is the second-line treatment for hepatic encephalopathy 4
• Precipitating factors such as constipation, infection, gastrointestinal bleeding, certain medications, and electrolyte imbalances should be identified and managed 5

Hepatorenal Syndrome (HRS)

• In patients with HRS-AKI, after withdrawing diuretics and treating precipitating factors, volume challenge with IV albumin (1 g/kg, maximum 100 g/day) is recommended for 48 hours 1
• Vasoconstrictors (terlipressin 0.5-2.0 mg IV q6h or continuous infusion) and albumin (20-40 g/day) are recommended for patients with Stage 2 or greater HRS-AKI 1
• Terlipressin improves the rate of reversal of hepatorenal syndrome from 39% to 18% 4

Hepatocellular Carcinoma (HCC) Screening

• Patients with cirrhosis should be screened for HCC with imaging studies (preferably MRI, or CT, ultrasound) every six months 1, 5

Special Considerations

• Patients with HIV-HBV coinfection have higher risk of progression to cirrhosis and should be monitored closely 1
• Renal function monitoring is particularly important in patients with multiple risk factors for renal impairment 1
• Growth factors such as recombinant erythromycin or G-CSF can help overcome hematological complications in cirrhotic patients 1

Liver Transplantation

• Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 2
• Liver transplantation is the definitive treatment for HRS-AKI in cirrhosis but needs to be considered in the context of multiorgan failure and overall transplant candidacy 1