What is the treatment for decompensated liver cirrhosis?

Treatment for Decompensated Liver Cirrhosis

Immediate Priority: Treat the Underlying Cause

Etiological treatment must be initiated immediately, as this is the single most important intervention associated with decreased risk of further decompensation and increased survival. 1

For Hepatitis B-Related Decompensated Cirrhosis

• Initiate entecavir 1 mg daily or tenofovir monotherapy immediately, regardless of HBV DNA level, as these agents have potent antiviral efficacy and high genetic barrier to resistance. 1, 2
• Combination therapy with tenofovir plus lamivudine is an alternative first-line option. 2
• Never use interferon-α in decompensated cirrhosis—it is absolutely contraindicated due to risk of serious complications including infection and hepatic failure. 3, 2
• Entecavir demonstrates superior HBV DNA suppression compared to adefovir (57% vs 20% undetectability at week 48) and improves Child-Pugh scores in almost half of treatment-naïve patients. 2

For Hepatitis C-Related Decompensated Cirrhosis

• Direct-acting antivirals improve liver function and reduce portal hypertension. 2, 4

For Alcohol-Related Decompensated Cirrhosis

• Complete cessation of alcohol consumption can lead to "re-compensation" and improved outcomes in some patients. 2, 4

Management of Specific Complications

Ascites

• First-line treatment: sodium restriction plus spironolactone with or without furosemide. 1, 2
• Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L. 1, 2
• For tense ascites, perform initial therapeutic paracentesis followed by sodium restriction and diuretic therapy. 2
• Avoid NSAIDs—they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites. 2

Refractory Ascites

• Options include serial large-volume paracentesis, transjugular intrahepatic portosystemic stent-shunt (TIPS), or liver transplantation. 2
• Patients requiring paracenteses more frequently than every 2 weeks likely have poor dietary compliance. 2

Hepatic Encephalopathy

• Lactulose is first-line therapy, reducing mortality and recurrent overt hepatic encephalopathy. 1, 4
• Oral non-absorbable disaccharides may prevent the development of hepatic encephalopathy. 2

Variceal Bleeding

• Initiate vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopic confirmation. 1, 2
• Antibiotic prophylaxis is mandatory: use ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings; use oral norfloxacin 400 mg twice daily in remaining patients. 1, 2
• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, target 7-9 g/dL. 2, 4
• Endoscopic band ligation should be performed within 12 hours of admission once hemodynamic stability is achieved. 2
• TIPS should be used as rescue therapy for persistent bleeding or early rebleeding. 2

Spontaneous Bacterial Peritonitis (SBP)

• Norfloxacin prophylaxis reduces risk of SBP and hepatorenal syndrome, though use is limited by potential for resistant bacteria. 1

Strategies to Prevent Disease Progression

Non-Selective Beta-Blockers

• Propranolol in responders decreases risk of ascites, hepatorenal syndrome, SBP, and hepatic encephalopathy beyond variceal bleeding prevention. 1, 4
• Use with caution in patients with severe or refractory ascites. 2

Anticoagulation

• Enoxaparin may delay hepatic decompensation and improve survival in patients with Child-Pugh scores 7-10 by preventing portal vein thrombosis and reducing intestinal barrier damage. 4

Statins

• Statins may reduce portal hypertension and improve survival through pleiotropic effects, though validation studies are needed. 1

Critical Interventions to Avoid

• Avoid nephrotoxic drugs, large volume paracentesis without albumin replacement, and hypotensive drugs during acute variceal hemorrhage. 2, 4
• Do not use beta-blockers during acute bleeding episodes. 4

Liver Transplantation Considerations

• Early referral for liver transplantation evaluation is essential for appropriate candidates, as decompensation significantly worsens prognosis. 1
• Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation. 1, 4
• Patients with low MELD scores but grade 3 ascites or overt hepatic encephalopathy have significant mortality and should be considered for transplantation despite low MELD. 5

Monitoring and Follow-Up

• Remote monitoring technologies and telemedicine can improve outcomes and reduce hospital readmissions. 2
• Heart rate variability monitoring may identify patients at risk of decompensation. 2, 4
• Clinical improvement from antiviral therapy often requires 3-6 months, during which some patients may progress to hepatic failure, necessitating liver transplantation consideration. 3