What should be included in routine blood work for an adult patient with cirrhosis?

Routine Blood Work in Cirrhosis

Patients with cirrhosis require regular laboratory monitoring every 3-6 months including complete blood count, comprehensive metabolic panel (bilirubin, albumin, AST, ALT, creatinine), and prothrombin time/INR, with more frequent testing during clinical deterioration. 1

Essential Laboratory Tests

Core Hepatic Function Markers

• Serum bilirubin is the single best test of overall liver function and the most critical prognostic marker in cirrhosis, essential for calculating MELD and Child-Pugh scores 1
• Albumin reflects hepatic synthetic function and is a key component of both Child-Pugh and MELD scoring systems 1
• Prothrombin time/INR assesses coagulation factor synthesis and contributes to prognostic scoring, though it can be misleading due to rebalanced hemostasis in cirrhosis 1, 2

Hepatocellular Injury Monitoring

• AST and ALT should be monitored every 3-6 months to track hepatocellular injury trends, with more frequent testing if clinical deterioration occurs 1
• The AST:ALT ratio >1 indicates advanced fibrosis/cirrhosis and can provide prognostic information even when both values are within normal range 2

Hematologic Parameters

• Complete blood count including platelet count monitors for thrombocytopenia from splenic sequestration and serves as a surrogate marker for portal hypertension 1
• Platelet count <150,000/mm³ suggests clinically significant portal hypertension 1
• Hemoglobin/hematocrit assesses for anemia from gastrointestinal bleeding, nutritional deficiencies, or hypersplenism 1

Renal Function

• Creatinine and calculated GFR are essential as renal dysfunction affects prognosis and is incorporated into MELD score 1

Hepatocellular Carcinoma Surveillance

• Abdominal ultrasound every 6 months is the standard surveillance modality for hepatocellular carcinoma in all cirrhosis patients 1
• Serum alpha-fetoprotein (AFP) every 6 months is recommended, though ultrasound remains the primary screening tool 1
• Rising AFP without a visible liver mass warrants additional imaging with multiphasic CT or MRI 1

Etiology-Specific Monitoring

• For hepatitis B-related cirrhosis, monitor HBV DNA to assess viral suppression 1
• For hepatitis C-related cirrhosis, monitor HCV RNA to assess viral suppression 1

Prognostic Scoring Systems

• Calculate Child-Pugh and MELD scores regularly using bilirubin, albumin, INR, and creatinine to assess disease severity and prognosis 1
• Child-Pugh Class A indicates compensated cirrhosis, while Classes B and C indicate decompensation 1
• MELD score is particularly useful for transplant evaluation and predicting short-term mortality 1

Portal Hypertension Assessment

• Platelet count <150,000/mm³ suggests clinically significant portal hypertension 1
• Splenomegaly on imaging indicates portal hypertension 1
• Consider esophagogastroduodenoscopy for variceal screening when platelet count or liver stiffness thresholds are crossed, with surveillance every 1-2 years thereafter 1

Monitoring Frequency

• Every 3-6 months for stable compensated cirrhosis: CBC, comprehensive metabolic panel, liver function tests 1
• Every 6 months: ultrasound and AFP for HCC surveillance 1
• More frequently if decompensated cirrhosis or clinical deterioration occurs 1
• Annually for endoscopic variceal surveillance once varices are detected 1

Critical Pitfalls to Avoid

• Do not assume improving transaminases indicate overall improvement in liver function—bilirubin, albumin, and INR are better markers of hepatic synthetic capacity and prognosis 1
• Avoid relying solely on PT/INR for bleeding risk assessment before procedures, as cirrhosis creates a rebalanced hemostatic state and traditional coagulation tests inadequately predict bleeding 1, 2
• Do not discontinue HCC surveillance even with improving enzymes, as hepatocellular carcinoma risk persists and surveillance must continue every 6 months 1
• Monitor for decompensation events including ascites, encephalopathy, variceal bleeding, or jaundice, which indicate transition from compensated to decompensated cirrhosis 1
• Do not perform routine extensive preprocedural coagulation testing (repeated PT/INR or platelet counts) before common gastrointestinal procedures in stable cirrhosis patients, as these tests do not predict bleeding risk 2

Real-World Context

Despite clear recommendations, surveillance remains suboptimal in the United States, with less than 30% of patients receiving appropriate laboratory monitoring every 6-12 months and less than 10% receiving adequate HCC or variceal surveillance 3. This emphasizes the need for systematic approaches to ensure adherence to monitoring guidelines.