What is the overall management of Chronic Liver Disease (CLD)?

Overall Management of Chronic Liver Disease

The management of chronic liver disease requires treating the underlying etiology to prevent progression to cirrhosis and hepatocellular carcinoma, implementing surveillance protocols once cirrhosis develops, and managing complications through lifestyle modifications, vaccinations, and monitoring for portal hypertension sequelae. 1

Treat the Underlying Etiology

The cornerstone of CLD management is addressing the specific cause to halt disease progression 1:

Viral Hepatitis

• Antiviral therapy for chronic hepatitis B and C is essential - sustained HBV suppression and HCV sustained viral response prevent progression to cirrhosis and reduce (but do not eliminate) HCC risk 1
• HBV DNA levels should be monitored using real-time PCR assays, expressed in IU/ml 1
• All patients should be tested for co-infections with HDV, HCV, and/or HIV 1
• Even after cirrhosis develops, antiviral therapy prevents decompensation and reduces HCC incidence 1

Alcohol-Related Liver Disease

• Complete alcohol abstinence is mandatory - heavy drinking (>4 drinks/day or >14 drinks/week in men; >3 drinks/day or >7 drinks/week in women) must be avoided 1
• Alcohol accounts for approximately 36% of liver cancers in Western populations 1

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD/NAFLD)

• Weight loss of 5-7% improves steatohepatitis; ≥10% may improve fibrosis 1, 2
• Dietary modifications coupled with regular physical activity are the primary interventions 3, 2
• Physical activity improves hepatic steatosis even without weight loss 2
• Bariatric surgery is not contraindicated in obese patients with NAFLD/NASH without established cirrhosis 1

Prevention Strategies

Vaccinations

• Hepatitis B vaccination for all infants (universal childhood immunization), high-risk adults, and exposed individuals 1
• Hepatitis A vaccination for all anti-HAV negative patients with chronic liver disease 1
• Taiwan's universal HBV vaccination program reduced HCC rates by 69% (rate ratio 0.31) over 20 years 1

Lifestyle Modifications

• Coffee consumption should be encouraged - decreases HCC risk in patients with chronic liver disease 1
• Regular weight-bearing exercise 1
• Smoking cessation 1
• Adequate nutrition to maintain body mass index >19 kg/m² 1

Assessment and Monitoring

Initial Evaluation

• Biochemical markers: AST, ALT, GGT, alkaline phosphatase, bilirubin, albumin, globulins, complete blood count, prothrombin time 1
• Hepatic ultrasound 1
• Screen for other causes: autoimmune markers, metabolic disorders, steatosis 1

Liver Biopsy Indications

• Recommended when histology will influence treatment decisions - particularly for determining degree of necroinflammation and fibrosis 1
• Not required in patients with clinical cirrhosis or when treatment is indicated regardless of fibrosis stage 1
• Transient elastography offers high diagnostic accuracy for cirrhosis detection, though results may be confounded by severe inflammation with high ALT 1

HCC Surveillance

• 6-monthly ultrasound and AFP measurement for all cirrhotic patients 1
• Also indicated for certain chronic HBV patients without cirrhosis 1
• Surveillance should not be offered to Child B8 or worse patients ineligible for transplant, or ECOG ≥2 performance status 1
• One-third of cirrhotic patients will develop HCC during their lifetime 1

Variceal Screening

• Endoscopic screening for esophageal varices when platelet count <200,000/mm³, albumin <40 g/L, or bilirubin >20 μmol/L 1
• Follow standard screening and prophylaxis protocols as for other chronic liver diseases 1

Management of Complications

Osteoporosis Prevention and Treatment

• All patients with cirrhosis or severe cholestasis (bilirubin >3× upper limit for >6 months) require bone density assessment 1, 4
• Calcium supplementation (1-1.2 g/day) plus vitamin D₃ (400-800 IU/day) for all cholestatic patients 1
• DEXA scan at presentation; repeat annually based on cholestasis severity 1
• Bisphosphonates (e.g., alendronate) indicated for T-score <-2.5 or pathological fracture 1
• Consider treatment at T-score <-1.5 1

Fat-Soluble Vitamin Supplementation

• Parenteral vitamin K prophylactically before invasive procedures in overt cholestasis and for bleeding 1
• Vitamins A, E, K supplemented enterally in adults with overt cholestasis, steatorrhea, or documented deficiency 1

Cardiovascular Risk Management

• Statins can be safely used to treat dyslipidemia in NAFLD/NASH patients - no increased risk of serious liver injury 1
• NAFLD patients have increased cardiovascular disease risk; cardiovascular disease is their most common cause of death 1
• Statins should not be used specifically to treat NASH (lack of histological endpoint data) 1

Common Pitfalls to Avoid

• Do not avoid statins in CLD patients - the historical reluctance is unfounded; serious statin-induced liver injury is rare 1
• Do not routinely repeat liver biopsies in NAFL or NASH patients - current evidence does not support this practice 1
• Do not use NSAIDs - avoid in all patients with chronic liver disease 5
• Do not supplement iron unless specifically indicated - only when appropriate for documented deficiency 5
• Do not continue HCC surveillance in decompensated patients ineligible for curative therapy - absolute risk versus harm must be individualized 1