What labs and monitoring are recommended for patients with cirrhosis?

Laboratory Monitoring for Patients with Cirrhosis

All patients with established cirrhosis should undergo comprehensive laboratory monitoring every 6 months, including a complete hepatic function panel (bilirubin, AST, ALT, alkaline phosphatase, albumin, PT/INR), complete blood count with platelet count, and renal function tests (creatinine, BUN) to calculate prognostic scores and detect complications early. 1

Initial Diagnostic Laboratory Panel

When cirrhosis is first diagnosed or suspected, obtain a comprehensive baseline assessment:

• Hepatic function panel: Bilirubin (total and conjugated), AST, ALT, alkaline phosphatase, GGT, albumin, and PT/INR 1
• Complete blood count: Essential for detecting thrombocytopenia (suggesting portal hypertension) and other cytopenias indicating advanced disease 1, 2
• Renal function: Creatinine and BUN are critical for MELD score calculation and detecting hepatorenal syndrome 1
• Alpha-fetoprotein (AFP): Baseline measurement for hepatocellular carcinoma surveillance 2

Key Interpretation Points

• Elevated conjugated bilirubin indicates advanced disease or biliary obstruction 1
• AST/ALT ratio >1 is characteristic of cirrhosis, though the magnitude of elevation does not correlate with disease severity 1, 2
• Thrombocytopenia (low platelet count) serves as a surrogate marker for portal hypertension and advanced disease 1
• Prolonged PT/INR reflects impaired hepatic synthetic function and is critical for Child-Pugh and MELD scoring 1
• Low albumin indicates impaired synthetic function and is part of prognostic scoring systems 1

Etiologic Workup

Determine the underlying cause of cirrhosis with targeted testing:

• Viral hepatitis: Hepatitis B panel (HBsAg, HBeAg, anti-HBe, HBV DNA), hepatitis C antibody with confirmatory viral load if positive 1, 2
• Hemochromatosis screening: Ferritin and transferrin saturation 1, 3
• Autoimmune markers: If etiology remains unclear 1
• Alpha-1 antitrypsin level: Screen for alpha-1 antitrypsin deficiency 1
• Ceruloplasmin: Consider for Wilson disease, particularly in younger patients 1
• Coinfection screening: HIV, hepatitis D, and hepatitis A antibody status 2

Routine Monitoring Schedule for Established Cirrhosis

Every 6 Months (All Patients)

Standard monitoring interval for compensated cirrhosis includes: 1, 4

• Liver function tests: Bilirubin, AST, ALT, alkaline phosphatase, albumin 1
• Coagulation studies: PT/INR 1
• Complete blood count: Including platelet count 1
• Renal function: Creatinine and BUN 1
• Prognostic scoring: Calculate Child-Pugh score, MELD score, and albumin-bilirubin grade 1, 4
• Non-invasive fibrosis markers: APRI, FIB-4, and GPR indices 1
• Hepatocellular carcinoma surveillance: Abdominal ultrasound and AFP 3, 5

More Frequent Monitoring (Every 1-3 Months)

Patients with decompensated cirrhosis or active complications require closer surveillance: 6

• Liver function tests every 1-3 months 6
• Clinical assessment for signs of decompensation 4
• Renal function monitoring for hepatorenal syndrome 1

Complication-Specific Laboratory Testing

Ascites Management

When ascites is present or newly develops, perform diagnostic paracentesis immediately without delay: 1

• Ascitic fluid cell count with differential: To rule out spontaneous bacterial peritonitis (SBP) 1
• Ascitic fluid total protein: Part of standard ascitic fluid analysis 1
• Serum-ascites albumin gradient (SAAG): Confirms portal hypertension as cause 1
• Ascitic fluid culture: Essential for detecting infection 1
• Additional tests based on clinical suspicion: Cytology, amylase, BNP, adenosine deaminase 1

Critical pitfall: Diagnostic paracentesis should be performed on hospital admission in all patients with ascites to rule out SBP, as this is a life-threatening complication requiring immediate treatment. 1

Varices Screening

• Upper endoscopy: Indicated for all patients with newly diagnosed cirrhosis unless low-risk criteria are met (platelets >150,000 and liver stiffness <20 kPa by transient elastography) 6

Hepatic Encephalopathy

• Ammonia levels: May be obtained but are not required for diagnosis or management decisions 5
• Clinical assessment remains the primary diagnostic tool 5

Critical Clinical Pitfalls to Avoid

Delayed Diagnosis

Do not wait for liver enzymes to reach high thresholds (>1.5-2× upper limit of normal) before pursuing evaluation, as this delays diagnosis. 1 Use age- and sex-normative values for interpretation. 1

Persistent Abnormalities

Any persistent laboratory abnormalities over 3-6 months warrant further evaluation, even if only mildly elevated. 1 Patients with hepatitis C or nonalcoholic fatty liver disease may have normal or minimally elevated ALT yet still progress to cirrhosis. 2

Timing of Testing

Perform screening during clinical stability to avoid transient elevations from acute illness. 1 Recognize that the magnitude of liver enzyme elevation does not correlate with disease severity or prognosis. 2

Spontaneous Bacterial Peritonitis

Never delay diagnostic paracentesis in hospitalized patients with ascites—perform immediately on admission to rule out SBP, as delayed diagnosis significantly increases mortality. 1

Special Monitoring Considerations

Patients on Antiviral Therapy

For patients receiving treatment for viral hepatitis:

• Nucleos(t)ide analogue therapy: Monitor liver function tests and viral DNA every 1-6 months initially, then every 3-6 months after virological response 2
• Peginterferon therapy: CBC and ALT monthly; viral DNA after 1-3 months to assess primary response 2
• Quantitative HBsAg: Monitor at baseline, 12 weeks, 24 weeks, and end of treatment to predict response 2

Alcohol-Related Liver Disease

Patients with alcohol-related cirrhosis require additional monitoring:

• Mean corpuscular volume (MCV): Often elevated in active alcohol use 6
• GGT: Sensitive marker for ongoing alcohol consumption 6
• Regular assessment of alcohol use and referral to addiction services 6