What are the treatment options for a patient with hepatic cirrhosis?

Treatment of Hepatic Cirrhosis

The treatment of cirrhosis requires addressing the underlying etiology first, followed by prevention and management of complications through dietary sodium restriction, diuretics, and regular monitoring for hepatocellular carcinoma. 1

Treat the Underlying Cause First

The most critical intervention is eliminating or treating the causative factor, as this can dramatically alter prognosis and prevent progression 1, 2:

• Alcohol-related cirrhosis: Complete abstinence is essential and can result in dramatic improvement within months. Patients with Child-Pugh class C cirrhosis who stop drinking have approximately 75% 3-year survival, while those who continue drinking have 0% survival at 3 years 1, 2

• Hepatitis B: Antiviral therapy with tenofovir or entecavir (first-line monotherapy) improves liver function and reduces complications in HBV-related cirrhosis 1, 2. These agents are preferred due to their potency and minimal resistance risk 2

• Hepatitis C: Antiviral therapy can eradicate the virus and resolve chronic liver disease in approximately half of patients 3

• Nonalcoholic steatohepatitis: Address metabolic risk factors including obesity 4

Critical caveat: Peginterferon alfa is contraindicated in decompensated cirrhosis but can be used in well-compensated cirrhosis 2

Nutritional Management

Specific dietary interventions are foundational 1, 4:

• Sodium restriction: 2000 mg/day (88 mmol/day) for ascites management 1, 2
• Protein intake: 1.2-1.5 g/kg/day to prevent sarcopenia and protein catabolism 4, 1, 2
• Caloric intake: 35-40 kcal/kg/day 4, 1
• Meal frequency: 4-6 small meals per day including a night snack to prevent catabolism 4

Avoid long-term protein restriction as it induces protein catabolism, hepatic dysfunction, and sarcopenia 4

Management of Ascites

Use a stepwise approach 1, 2, 5, 6:

1. Dietary sodium restriction (as above) plus protein supplementation 2

2. Diuretic therapy - start with aldosterone antagonist:

   • Spironolactone: Start 50-100 mg/day, increase up to 400 mg/day as needed 2, 5
   • Add furosemide if needed: Start 20-40 mg/day, increase up to 160 mg/day 2, 6
   • In cirrhosis, initiate therapy in a hospital setting and titrate slowly 5

3. Large-volume paracentesis for refractory ascites:

   • Administer 6-8 g albumin per liter of ascites drained 1, 2

Important warning: Sudden alterations of fluid and electrolyte balance may precipitate hepatic coma; strict observation is necessary during diuresis 6

Prevention of Variceal Bleeding

For patients with portal hypertension 7:

• Nonselective β-blockers (carvedilol or propranolol) reduce risk of decompensation or death (16% vs 27% with placebo over 3 years) 7

If acute variceal bleeding occurs 2:

• Start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately before endoscopy 2
• Perform gastroscopy within 12 hours after hemodynamic stabilization 2
• Give antibiotic prophylaxis (ceftriaxone 1 g/24h for up to 7 days) 2

Management of Hepatic Encephalopathy

First-line therapy 4, 7:

• Lactulose: Reduces mortality (8.5% vs 14% with placebo) and prevents recurrent overt hepatic encephalopathy (25.5% vs 46.8%) 7
• Can be given orally or as enema in severe cases (West Haven grade ≥3) 4

Second-line options 4:

• Rifaximin: Can be combined with lactulose 4
• Oral branched-chain amino acids (BCAA) or IV L-ornithine L-aspartate (LOLA) as adjuncts 4

Always identify and treat precipitating factors: GI bleeding, infection, constipation, excessive protein intake, dehydration, electrolyte imbalance, psychoactive medications, acute hepatic injury 4

Management of Hepatorenal Syndrome

For HRS-AKI 2, 7:

1. Withdraw diuretics and treat precipitating factors 2
2. Volume challenge: IV albumin 1 g/kg (maximum 100 g/day) for 48 hours 2
3. Vasoconstrictors: Terlipressin 0.5-2.0 mg IV q6h plus albumin 20-40 g/day for Stage 2 or greater HRS-AKI 2
   • Terlipressin improves reversal rate from 18% to 39% 7

Hepatocellular Carcinoma Surveillance

All patients with cirrhosis require HCC screening 2:

• Imaging (preferably MRI, or CT, ultrasound) every 6 months 2
• The risk of HCC remains even after successful treatment of underlying cause 2

Liver Transplantation

Indications 4, 1:

• Decompensated cirrhosis (Child-Pugh class B or C) with small HCC 4, 1
• Severe hepatic encephalopathy not responding to medical treatment 4
• Hepatorenal syndrome in appropriate candidates 2

Critical surgical consideration: Only 10-30% of HCC patients are eligible for surgery initially. Surgery in cirrhosis carries substantial morbidity and mortality: 30-50% in Child-Pugh class B or C, but only 5-10% in Child-Pugh class A 4

Monitoring and Follow-up

• Regular monitoring for complications even after treating underlying cause 2
• Consider telemedicine and remote monitoring for early detection of complications and reducing hospital readmissions 1
• Monitor renal function closely, especially in patients with multiple risk factors 2

Common Pitfalls to Avoid

• Do not delay treatment of underlying liver disease, as this reduces effectiveness of preventing progression 3
• Do not restrict protein long-term despite concerns about encephalopathy 4
• Do not use peginterferon in decompensated cirrhosis 2
• Do not initiate diuretics without sodium restriction first 1, 2
• Do not forget albumin replacement with large-volume paracentesis 1, 2