What is the treatment for cirrhosis?

Treatment of Cirrhosis

The treatment of cirrhosis must prioritize treating the underlying etiology to prevent progression, combined with systematic management of complications through sodium restriction, diuretics, and surveillance for hepatocellular carcinoma, with liver transplantation reserved for decompensated disease. 1, 2

Treatment Based on Disease Stage

Compensated Cirrhosis (Child-Pugh Class A)

The primary goal is preventing decompensation through aggressive treatment of the underlying cause. 1

Viral Hepatitis-Related Cirrhosis

• For HBV-related compensated cirrhosis, initiate monotherapy with either tenofovir or entecavir as first-line agents due to their potent antiviral efficacy and high genetic barrier to resistance 1, 2
• Treatment should begin if HBV DNA ≥2,000 IU/mL regardless of ALT levels 2
• Peginterferon alfa can be used in well-compensated cirrhosis with careful monitoring, though it carries decompensation risk 1, 2
• Long-term antiviral therapy decreases progression to decompensation and reduces hepatocellular carcinoma risk 1

Alcohol-Related Cirrhosis

• Complete and permanent alcohol cessation is the cornerstone of treatment and can lead to dramatic improvement within months 1, 3
• Patients with Child-Pugh class C who stop drinking have approximately 75% 3-year survival, while those who continue have 0% survival at 3 years 3

Decompensated Cirrhosis (Child-Pugh Class B/C)

Antiviral Treatment

• For HBV-related decompensated cirrhosis, entecavir and tenofovir monotherapy are the preferred first-line options 1
• All patients should receive treatment regardless of HBV DNA level 2
• Peginterferon alfa is absolutely contraindicated in decompensated cirrhosis due to risk of sepsis, infection, and hepatic failure 4, 1, 2
• Child-Pugh class B patients can be treated by experienced specialists with careful monitoring 1
• Child-Pugh class C patients face high risk of severe complications with standard treatment regimens 1

Management of Specific Complications

Ascites Management

First-line treatment combines dietary sodium restriction (≤2 g/day or 88 mmol/day) with diuretic therapy. 1, 2, 3

Diuretic Regimen

• Start spironolactone 50-100 mg/day, increasing up to 400 mg/day as needed 1, 2
• Add furosemide 20-40 mg/day if needed, increasing up to 160 mg/day 1
• Fluid restriction is unnecessary unless serum sodium falls below 120-125 mmol/L 2

Large-Volume Paracentesis

• For tense ascites (Grade 3), perform therapeutic paracentesis followed by sodium restriction and diuretics 1, 2
• Administer 6-8 g of albumin per liter of ascites drained 1

Refractory Ascites

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

Critical Pitfall: NSAIDs must be avoided as they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites 2

Variceal Bleeding Management

Initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) immediately upon suspicion of variceal bleeding, before endoscopic confirmation. 1, 2

Acute Management Protocol

• Start antibiotic prophylaxis immediately: ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings 1, 2
• Perform gastroscopy within 12 hours after achieving hemodynamic stability 1, 2
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL, targeting 7-9 g/dL 1, 2
• Administer erythromycin 250 mg IV 30-120 minutes before endoscopy to improve visibility (unless QT prolongation present) 2
• TIPS should be used as rescue therapy for uncontrolled bleeding or early rebleeding 1, 2

Hepatorenal Syndrome (HRS-AKI)

After withdrawing diuretics and treating precipitating factors, administer volume challenge with IV albumin 1 g/kg (maximum 100 g/day) for 48 hours. 1

• For Stage 2 or greater HRS-AKI, add vasoconstrictors: terlipressin 0.5-2.0 mg IV every 6 hours (or continuous infusion) plus albumin 20-40 g/day 1
• Liver transplantation is the definitive treatment but must be considered in context of multiorgan failure and transplant candidacy 1

Spontaneous Bacterial Peritonitis (SBP)

• Perform diagnostic paracentesis without delay in all cirrhotic patients with ascites on hospital admission 2
• Ascitic neutrophil count >250/mm³ confirms diagnosis 2
• Initiate immediate empirical antibiotic therapy based on severity and local resistance patterns 2

Nutritional Management

Protein supplementation is essential: provide 1.2-1.5 g/kg/day of protein. 1, 2

• Total caloric intake should be 35-40 kcal/kg/day 3
• Carbohydrate intake: 2-3 g/kg/day 3
• Rapid nutritional screening should be performed in all patients, assuming high malnutrition risk if BMI <18.5 kg/m² or Child-Pugh C 2
• Assess for sarcopenia using CT scan, anthropometry, DEXA, or bioelectrical impedance analysis 2

Common Pitfall: Excessive bed rest should be avoided as it causes muscle atrophy; patients can be managed outpatient unless complicated by bleeding, encephalopathy, infection, hypotension, or liver cancer 2

Hepatocellular Carcinoma Surveillance

All patients with cirrhosis require screening for hepatocellular carcinoma with imaging (preferably MRI, or CT, or ultrasound) every 6 months. 1, 5

• Continuous monitoring is needed even after successful treatment of the underlying cause, as HCC risk persists 1

Medications to Avoid

Discontinue or avoid the following medications: 1, 2

• NSAIDs (reduce urinary sodium excretion)
• ACE inhibitors
• Angiotensin receptor blockers
• Nephrotoxic agents

Hepatic Encephalopathy Prevention

• Rifaximin (550 mg twice daily) can be used for prevention of recurrent hepatic encephalopathy in appropriate patients 6
• Oral non-absorbable disaccharides may prevent development of hepatic encephalopathy 2

Monitoring and Follow-up

• Clinical assessment with laboratory tests and calculation of Child-Pugh and MELD scores should occur every 6 months 7
• Remote monitoring technologies and telemedicine can improve outcomes and reduce hospital readmissions 2
• Bluetooth-linked weighing scales and smartphone apps enable early intervention for weight changes 2

Liver Transplantation Criteria

Evaluation for liver transplantation is indicated for: 7

• MELD score ≥15
• Any complications of cirrhosis
• Hepatocellular carcinoma meeting transplant criteria

Transplantation is the optimal therapy for small-size, otherwise resectable HCC in patients with moderate to severe cirrhosis (Child-Pugh class B or C). 3

Special Populations

• Patients with HIV-HBV coinfection have higher risk of progression and require closer monitoring 1
• Renal function monitoring is particularly important in patients with multiple risk factors for renal impairment 1