What is the treatment for cirrhosis of the liver?

Treatment of Cirrhosis of the Liver

The treatment of cirrhosis should focus on addressing the underlying cause, preventing disease progression, and managing complications through a comprehensive approach that includes medication, lifestyle modifications, and regular monitoring to improve survival and quality of life. 1

Treatment of Underlying Etiology

• Complete cessation of alcohol consumption is the cornerstone of treatment for alcoholic cirrhosis and can lead to dramatic improvement in the reversible component of alcoholic liver disease, with patients with Child-Pugh class C cirrhosis who stop drinking having approximately 75% 3-year survival, compared to 0% survival at 3 years for those who continue drinking 1
• Antiviral therapy with tenofovir, entecavir, or peginterferon-α can improve liver function and reduce complications in patients with HBV-related cirrhosis 1
• Direct-acting antivirals for HCV-related decompensated cirrhosis improve liver function and portal hypertension 2
• Treatment effectiveness varies based on disease severity at the time of intervention, with early intervention offering better outcomes 3

Preventing Disease Progression

• Enoxaparin can delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 by preventing portal vein thrombosis and reducing intestinal barrier damage 2
• Nonselective β-blockers (carvedilol or propranolol) reduce the risk of decompensation or death compared with placebo (16% vs 27% in a 3-year randomized clinical trial) 4
• Propranolol reduces portal hypertension and decreases risk of various complications (variceal bleeding, ascites, hepatorenal syndrome, spontaneous bacterial peritonitis, encephalopathy) in responders 2

Nutritional Management

• Dietary sodium restriction (2000 mg/day or 88 mmol/day) is essential for managing ascites 1
• Nutritional intake for cirrhotic patients should include carbohydrate: 2-3 g/kg/day, protein: 1.2-1.5 g/kg/day, and caloric intake: 35-40 kcal/kg/day 1

Management of Specific Complications

Ascites

• Oral diuretics are the mainstay of treatment alongside sodium restriction for ascites management 1
• Combination aldosterone antagonist and loop diuretics are more effective than sequential initiation, with higher rates of ascites resolution (76% vs 56%) and lower rates of hyperkalemia (4% vs 18%) 4
• Large-volume paracentesis (LVP) with albumin replacement is recommended for refractory ascites 1, 3

Hepatic Encephalopathy

• Lactulose is associated with reduced mortality relative to placebo (8.5% vs 14%) and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 4
• Early identification and management of hepatic encephalopathy can improve outcomes 2

Hepatorenal Syndrome

• Early identification and management of renal dysfunction is crucial for improving survival 2
• Terlipressin improves the rate of reversal of hepatorenal syndrome from 39% to 18% 4

Variceal Bleeding

• Patients with acute episodes of gastrointestinal bleeding should be monitored in an intensive care unit and have endoscopy performed within 24 hours 5
• Antibiotic prophylaxis with ceftriaxone for up to seven days is recommended in patients with advanced cirrhosis and active bleeding 2

Symptom Management

• Hydroxyzine can improve sleep dysfunction, pickle brine and taurine can reduce muscle cramps, and tadalafil can improve sexual dysfunction in men 4

Monitoring and Follow-up

• Use the Child-Pugh score for initial stratification of cirrhosis severity, with scores of 7-10 indicating decompensated disease 2
• MELD and MELD-Na scores are essential for transplant prioritization 2
• Clinical assessment with laboratory tests and calculation of the Child-Pugh and MELD scores should occur every 6 months 6
• Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every six to 12 months 7, 5
• Consider telemedicine and remote monitoring technologies to help with early detection of complications and reduce hospital readmissions 1, 2, 3

Liver Transplantation

• Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma 6
• Liver transplantation is potentially optimal therapy for small-size, otherwise resectable hepatocellular carcinoma in patients with moderate to severe cirrhosis (Child-Pugh class B or C) 1
• Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation 2

Common Pitfalls and Caveats

• Only 10-30% of patients initially presenting with hepatocellular carcinoma will be eligible for surgery, and surgery in patients with underlying cirrhosis can be associated with substantial morbidity and mortality (30-50% in Child-Pugh class B or C, but only 5-10% in Child-Pugh class A) 1
• Avoid nephrotoxic drugs, large volume paracentesis without albumin, beta-blockers during acute bleeding, and other hypotensive drugs in patients with decompensated cirrhosis 2
• Overuse of blood products may worsen portal hypertension in patients with decompensated cirrhosis 2
• Inappropriate use of nephrotoxic medications can precipitate hepatorenal syndrome 2
• Drugs with potential for hepatotoxicity should be avoided 6