What is the initial management for a patient with cirrhosis?

Initial Management of Cirrhosis

Begin with immediate identification and removal of the causative factor—alcohol abstinence for alcoholic cirrhosis, antiviral therapy for viral hepatitis, or treatment of metabolic/autoimmune disorders—as this is the cornerstone that can lead to dramatic improvement and potential reversal of early cirrhosis. 1, 2

Immediate Assessment and Risk Stratification

• Determine if the patient has compensated (asymptomatic) or decompensated cirrhosis (presence of ascites, hepatic encephalopathy, or variceal bleeding), as approximately 40% of patients are diagnosed only when complications develop 3
• Calculate Child-Pugh and MELD scores to assess disease severity and prognosis 4, 5
• Perform diagnostic paracentesis without delay if ascites is present to rule out spontaneous bacterial peritonitis 2

Address the Underlying Etiology

Alcoholic Cirrhosis

• Mandate complete alcohol abstinence immediately, as this can lead to "re-compensation" and excellent long-term outcomes in some patients with decompensated disease 6, 1
• Steatosis is reversible upon alcohol withdrawal, though alcoholic hepatitis may persist and progress even with abstinence 7

Viral Hepatitis-Related Cirrhosis

• Initiate antiviral therapy for HBV if HBV DNA ≥2,000 IU/mL using entecavir or tenofovir as first-line agents 2
• For decompensated cirrhosis, treat regardless of HBV DNA level; interferon-α is absolutely contraindicated due to risk of hepatic failure 2
• HCV treatment with direct-acting antivirals can improve liver function and reduce portal hypertension 2

Other Etiologies

• Address nonalcoholic fatty liver disease through obesity management 1, 5
• Treat autoimmune, cholestatic, or metabolic disorders as appropriate 1, 8

Dietary Management (Critical First-Line Intervention)

• Restrict sodium intake to 88 mmol/day (2000 mg/day), equivalent to a "no added salt" diet—dietary non-compliance is the most common cause of treatment failure 1, 2
• Prescribe 1.2-1.5 g/kg/day protein, 2-3 g/kg/day carbohydrate, and 35-40 kcal/kg/day total calories 1
• Fluid restriction is NOT necessary unless serum sodium drops below 120-125 mmol/L 6, 1, 2
• Avoid bed rest—excessive bed rest causes muscle atrophy; patients can be managed outpatient unless complicated by bleeding, encephalopathy, infection, or hypotension 2

Pharmacological Management for Ascites

Initial Diuretic Therapy

• Start with combination therapy: spironolactone 100 mg once daily PLUS furosemide 40 mg once daily, given as single morning doses to maximize compliance 1, 2
• This combination approach shortens time to ascites mobilization and maintains normokalemia better than sequential therapy 6
• Increase doses simultaneously every 3-5 days (maintaining 100 mg:40 mg ratio) if weight loss is inadequate, up to maximum doses of 400 mg/day spironolactone and 160 mg/day furosemide 6, 1, 9

Special Considerations for Diuretic Initiation

• In patients with cirrhosis and ascites, initiate spironolactone therapy in a hospital setting and titrate slowly due to risk of sudden electrolyte imbalances that can precipitate hepatic encephalopathy 9
• For patients with eGFR 30-50 mL/min/1.73 m², consider starting at 25 mg every other day due to hyperkalemia risk 9
• Clearance of spironolactone is reduced in cirrhosis; start with lowest dose and titrate slowly 9

Management of Tense Ascites

• Perform therapeutic paracentesis immediately—do not delay—followed by sodium restriction and oral diuretics 1, 2
• For large-volume paracentesis (>5L), administer albumin at 8g per liter of ascites removed to prevent circulatory dysfunction 1

Critical Medications to AVOID

• Discontinue NSAIDs immediately—they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive ascites to refractory ascites 1, 2
• Stop ACE inhibitors and angiotensin receptor blockers as they aggravate hypotension 6, 2
• Avoid all nephrotoxic agents 2

Monitoring Protocol

• Monitor serum electrolytes, creatinine, and weight regularly 1
• Measure 24-hour urinary sodium excretion if weight loss is inadequate 1
• Initial follow-up should occur every 2-4 weeks until stable 1
• Perform rapid nutritional screening assuming high malnutrition risk if BMI <18.5 kg/m² or Child-Pugh C 2

Immediate Liver Transplantation Evaluation

• Refer all patients with cirrhosis and ascites for transplantation evaluation, as 20% die within the first year of ascites diagnosis 1
• Transplantation offers definitive cure and should be considered for MELD score ≥15 or any decompensation event 4, 5

Gastroenterology Referral Triggers

• Any decompensation event (ascites, variceal bleeding, hepatic encephalopathy) requires immediate gastroenterology referral 2
• Refractory ascites not responding to maximum diuretic therapy 2
• Need for TIPS placement 2

Common Pitfalls to Avoid

• Delaying paracentesis in patients with tense ascites—this is a medical emergency 1
• Inadequate sodium restriction counseling—patients requiring paracentesis more frequently than every 2 weeks likely have poor dietary compliance 2
• Overly aggressive diuresis leading to electrolyte abnormalities or precipitating hepatorenal syndrome 1
• Failure to recognize spontaneous bacterial peritonitis—maintain high index of suspicion and perform diagnostic paracentesis liberally 1, 2
• Starting diuretics without hospital monitoring in patients with decompensated cirrhosis 9