What is the management approach for a patient with decompensated liver cirrhosis?

Management of Decompensated Liver Cirrhosis

Patients with decompensated liver cirrhosis require immediate initiation of oral nucleos(t)ide analogues (NAs) if HBV DNA is detectable at any level, alongside urgent evaluation for liver transplantation, as this represents a critical turning point with median survival dropping from 10-12 years to 1-2 years. 1, 2

Immediate Priorities

Etiological Treatment

• Start antiviral therapy immediately if hepatitis B-related, regardless of ALT levels or HBV DNA levels—even low-level viremia requires treatment in decompensated cirrhosis 1, 3
• Use entecavir 1 mg daily or tenofovir monotherapy as first-line agents due to potent antiviral efficacy and high genetic barrier to resistance 1, 3
• Never use interferon-α in decompensated cirrhosis—it is absolutely contraindicated due to risk of precipitating liver failure and serious infections 1
• Treating the underlying etiology (viral hepatitis, alcohol cessation, metabolic factors) reduces further decompensation risk and improves survival 4, 3

Liver Transplantation Evaluation

• Refer all patients with decompensated cirrhosis for transplant evaluation immediately—this is the definitive treatment 1, 2, 3
• Antiviral therapy can stabilize patients, improve Child-Turcotte-Pugh scores, and potentially delay or avoid transplantation in some cases 1
• Prolonged viral suppression may decrease need for transplantation, particularly in CTP class C cirrhosis 1, 2

Management of Specific Complications

Ascites Management

• Initiate spironolactone 100 mg daily in hospital setting with slow titration (can range 25-200 mg daily), given as sole agent for at least 5 days before dose adjustment 5
• Add furosemide (up to 160 mg daily) if needed, but monitor closely for electrolyte depletion and hepatic coma 6
• Moderate sodium restriction to 80-120 mmol/day (4.6-6.9 g salt) 2
• Perform diagnostic paracentesis in all patients with new-onset grade 2-3 ascites or hospitalized for complications 2
• Avoid nephrotoxic drugs, NSAIDs, and aminoglycosides—these can precipitate renal failure and convert diuretic-sensitive to refractory ascites 2, 4

Variceal Hemorrhage

• Start vasoactive medications (terlipressin, somatostatin, or octreotide) immediately upon suspicion, before endoscopic confirmation 2, 3
• Perform upper endoscopy within 12 hours of admission 2
• Administer prophylactic antibiotics immediately: ceftriaxone 1 g IV daily for up to 7 days in decompensated cirrhosis 2, 4
• Use endoscopic variceal ligation as treatment of choice for esophageal varices 2
• Apply restrictive transfusion strategy with hemoglobin threshold of 7 g/dL (target 7-9 g/dL) to avoid increasing portal pressure 2

Hepatic Encephalopathy

• Treat with lactulose or lactitol as first-line therapy—this reduces mortality and prevents recurrent overt hepatic encephalopathy 2, 4, 3
• Identify and treat precipitating factors: infections, bleeding, medications, electrolyte disturbances 2
• Screen for minimal hepatic encephalopathy using simple tests like animal naming 2

Renal Complications and Hepatorenal Syndrome

• Monitor renal function closely and avoid all nephrotoxic medications 2
• Follow EASL algorithm for hepatorenal syndrome management 2
• Consider renal replacement therapy as bridge to transplantation in end-stage renal failure 2

Critical Monitoring and Prevention

Hospital-Based Initiation

• All patients with decompensated cirrhosis should be managed in institutions capable of handling complications 1
• Initiate diuretic therapy in hospital setting with careful monitoring for sudden fluid/electrolyte shifts that can precipitate hepatic coma 5, 6

Secondary Prevention

• Start non-selective beta-blockers and/or endoscopic variceal ligation for secondary prophylaxis once bleeding controlled 2
• Use beta-blockers cautiously in patients with severe or refractory ascites 2
• Consider norfloxacin 400 mg twice daily for long-term infection prophylaxis to reduce spontaneous bacterial peritonitis and hepatorenal syndrome risk 4

Diabetes Management

• Screen for diabetes due to high prevalence in decompensated cirrhosis 2
• Use insulin therapy exclusively—it is the only evidence-based option for type 2 diabetes in this context 2
• Initiate treatment in hospital due to significant glucose variability and hypoglycemia risks 2

Common Pitfalls to Avoid

• Do not delay antiviral therapy waiting for specific HBV DNA thresholds—any detectable level requires immediate treatment in decompensated cirrhosis 1
• Do not use interferon under any circumstances in decompensated patients 1
• Do not restrict fluids unless serum sodium drops below 120-125 mmol/L 4
• Do not use aggressive diuresis—sudden alterations in fluid/electrolyte balance can precipitate hepatic coma 6
• Do not overlook transplant evaluation—decompensation is itself an indication for referral regardless of other interventions 4, 3