Management Approach for Patient with Liver Metastasis, Ascites, HBsAg Positivity, and AKI on CKD
Patients with liver metastasis, ascites, HBsAg positivity, and AKI on CKD require immediate initiation of antiviral therapy with entecavir or tenofovir AF (not tenofovir DF), along with careful management of ascites and renal dysfunction.
Initial Assessment and Management
- Confirm HBV infection status with complete viral panel including HBV DNA quantification, HBeAg, anti-HBe, and anti-HDV testing 1, 2
- Assess liver function with liver enzymes, bilirubin, albumin, prothrombin time, and platelet count to determine severity of liver disease 1
- Evaluate renal function with serum creatinine, blood urea nitrogen, electrolytes, and estimated GFR to classify AKI stage 1
- Perform diagnostic paracentesis to rule out spontaneous bacterial peritonitis and malignant ascites 1
- Screen for other precipitating factors of AKI including infections, GI bleeding, and nephrotoxic medications 1
Antiviral Management
- Initiate antiviral therapy immediately regardless of HBV DNA level or ALT since the patient has decompensated liver disease 1
- Choose entecavir or tenofovir AF as first-line therapy based on renal function 1
- For patients with creatinine clearance <50 mL/min, adjust dosing of antiviral medication: 3
- Avoid tenofovir DF due to risk of worsening renal function in patients with pre-existing kidney disease 1, 3
Ascites Management
- Discontinue diuretics immediately to prevent further renal deterioration 1, 4
- Consider therapeutic paracentesis with albumin replacement (8g albumin per liter of fluid removed) for tense ascites 1
- Restrict sodium intake to <5g/day (no added salt) 1
- Monitor for signs of abdominal compartment syndrome which can worsen renal function 1, 5
AKI Management
- Identify and treat precipitating factors of AKI: 1
- Discontinue all nephrotoxic medications including NSAIDs and beta-blockers 1
- Screen for and treat infections, particularly spontaneous bacterial peritonitis 1
- Administer volume expansion with 20% albumin (1g/kg body weight, maximum 100g) for two consecutive days if no obvious cause of AKI is identified 1
- If AKI persists or worsens despite initial management and meets criteria for hepatorenal syndrome (HRS-AKI), consider vasoconstrictor therapy with albumin 1
- Consider renal replacement therapy for: 1
- AKI secondary to acute tubular necrosis
- HRS-AKI in potential liver transplant candidates
- Severe electrolyte abnormalities or volume overload
Oncologic Considerations
- Prophylactic antiviral therapy is recommended for patients with HBV-related malignancy who undergo anticancer treatment, regardless of detectable serum HBV DNA 1
- Assess for potential drug-drug interactions between antiviral medications and planned cancer treatments 1
- For patients receiving systemic therapy for liver metastasis, monitor for HBV reactivation which may worsen liver function 1
Monitoring and Follow-up
- Monitor renal function (creatinine, electrolytes) daily during hospitalization 1
- Check HBV DNA levels and liver function tests regularly to assess response to antiviral therapy 1
- Monitor for signs of hepatic encephalopathy which may be precipitated by electrolyte disturbances or renal dysfunction 1
- Assess fluid status carefully when administering albumin due to risk of pulmonary edema 1
Pitfalls to Avoid
- Do not delay antiviral therapy while waiting for HBV DNA results in patients with decompensated liver disease 1
- Avoid nephrotoxic agents including contrast media, aminoglycosides, and NSAIDs 1
- Do not restart diuretics until renal function stabilizes 1
- Avoid tenofovir DF in patients with renal dysfunction; use entecavir or tenofovir AF instead 1, 3
- Do not overlook the possibility of HBV reactivation during cancer treatment, which requires prophylactic antiviral therapy 1