What is the recommended management plan for a patient with Chronic Liver Disease (CLD)?

Management of Chronic Liver Disease

The management of chronic liver disease requires identifying and treating the underlying etiology to prevent progression to cirrhosis and hepatocellular carcinoma, combined with systematic surveillance, nutritional optimization, and management of complications. 1, 2, 3

Treat the Underlying Cause First

The most critical step is addressing the specific etiology, as this can potentially reverse early cirrhosis and prevent end-stage liver disease 1, 2, 3:

Viral Hepatitis B

• Initiate entecavir 0.5 mg daily, tenofovir disoproxil fumarate 300 mg daily, or peginterferon alfa-2a for patients with elevated ALT and HBV DNA ≥2,000 IU/mL 1, 2
• All cirrhotic patients with detectable HBV DNA require treatment regardless of ALT levels 1, 2
• Monitor HBV DNA and ALT every 3-6 months during therapy 2
• Sustained viral suppression prevents cirrhosis progression and reduces (but does not eliminate) HCC risk 1, 2

Viral Hepatitis C

• Use direct-acting antivirals (DAAs) to achieve sustained viral response in all eligible patients 1, 2
• Monitor HCV RNA at weeks 4,8, and 12-24 depending on the regimen 3
• DAAs achieve high cure rates with minimal side effects 2, 3

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD/NAFLD)

• Lifestyle modification is the primary treatment, requiring 7-10% weight loss to improve steatohepatitis and achieve fibrosis regression 1, 2
• Create a 500-1000 kcal/day deficit: typically 1,200-1,500 kcal/day for women and 1,500-1,800 kcal/day for men 1, 2
• Weight loss must be gradual at 500-1000g per week maximum—rapid weight loss worsens liver disease 1, 2
• Implement a Mediterranean diet pattern with daily vegetables, fruits, fiber-rich cereals, nuts, fish or white meat, and olive oil—this reduces liver fat even without weight loss 1, 2
• Prescribe 150-300 minutes of moderate-intensity aerobic exercise per week or 75-150 minutes of vigorous-intensity exercise 1, 2
• Consider resmetirom if locally approved for non-cirrhotic MASH with significant fibrosis (stage ≥2) 2, 3
• Use incretin-based therapies (semaglutide, tirzepatide) for patients with type 2 diabetes or obesity when indicated 2, 3
• Bariatric surgery resolves NASH in 85% of patients at 1 year and is an option for those meeting national eligibility criteria 2, 3

Alcohol-Related Liver Disease

• Complete and permanent alcohol abstinence is mandatory for all patients 2, 3
• Even moderate alcohol consumption accelerates disease progression 4, 3

Risk Stratification and Surveillance Strategy

Use a stepwise approach with FIB-4 score followed by transient elastography to identify patients with advanced fibrosis who require closer monitoring 1, 2:

• Apply case-finding strategies in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological hepatic steatosis, particularly with type 2 diabetes or obesity 1, 2
• Manage low-risk patients in the community with lifestyle advice and cardiovascular risk reduction, reassessing with non-invasive tests after 3 years 2
• Fibrosis progresses in a significant proportion of individuals, so repeated assessment every 1-3 years is required in at-risk patients 2

Hepatocellular Carcinoma Surveillance

• Perform 6-monthly ultrasound and AFP measurement for all cirrhotic patients 1, 2, 3
• Lifelong HCC surveillance is required for cirrhotic patients, even after viral clearance 1, 2, 3
• Early treatment of underlying liver diseases before progression to cirrhosis is the most effective approach for preventing HCC 2

Management of Hepatic Encephalopathy

Identify and correct precipitating factors first—this resolves up to 90% of cases 1:

• Common precipitants include infection, GI bleeding, constipation, electrolyte abnormalities, and medications 3
• Lactulose is first-line treatment, titrated to achieve 2-3 soft stools per day 1
• Rifaximin is second-line or additional therapy for patients with recurrent episodes despite lactulose use 1
• Secondary prophylaxis with lactulose is recommended after the first episode of overt hepatic encephalopathy 1
• Do not rely exclusively on ammonia levels for diagnosis—they do not provide diagnostic, prognostic, or staging value 1
• Ensure adequate protein intake (1.2-1.5 g/kg/day) to prevent sarcopenia, which worsens hepatic encephalopathy 3

Nutritional Management

Most patients with chronic liver disease need adequate calories and protein more than they need to avoid specific foods 4:

• Split food intake into 3 main meals (breakfast, lunch, dinner) and 3 snacks (mid-morning, mid-afternoon, late evening)—the late-evening snack is most important 4
• Try to eat as many vegetables and fruits as possible 4
• Limit salt addition to food, but if this makes food unpleasant and reduces intake, report to your doctor 4
• Virtually no food other than alcohol actually damages the liver or is genuinely contraindicated 4

Bone Disease Management

Osteoporosis affects approximately 30% of patients with chronic liver disease, with higher prevalence in cholestatic conditions 4:

• Perform bone densitometry in patients with previous fragility fractures, those treated with corticosteroids, and before liver transplantation 4
• Provide supplements of calcium (1,000–1,500 mg/d) and 25-hydroxy-vitamin D (400–800 IU/d or 260 μg every 2 weeks) 4
• Repeat bone density in two years if therapy has commenced, and again at the end of treatment 4
• Consider bisphosphonates in all patients who have had a fragility fracture or have a T score <−2.5 4
• Treat hypogonadism: transdermal HRT for women, transdermal testosterone for hypogonadal men (after discussing theoretical HCC risks) 4

Management of Cardiometabolic Comorbidities

• Use statins for dyslipidemia in all NAFLD patients—they carry no increased risk of serious liver injury and reduce HCC risk by 37% 1
• Optimize treatment for type 2 diabetes, as patients with or who develop T2DM have higher risk of fibrosis progression 2
• Assess lipid profile, fasting glucose/HbA1c, waist circumference, and BMI regularly 2

Vaccination and Prevention

• Vaccinate against hepatitis B: all infants (universal childhood immunization), high-risk adults, and exposed individuals 1, 2
• Vaccinate against hepatitis A: all anti-HAV negative patients with chronic liver disease 1, 2
• Hepatitis B vaccination reduces HCC risk 2

Critical Pitfalls to Avoid

• Do not fail to seek precipitating factors in hepatic encephalopathy, which cause 90% of cases 1
• Do not use rapid weight loss strategies in MASLD—gradual weight loss at 500-1000g per week maximum is essential 1, 2
• Do not discontinue HCC surveillance after achieving sustained viral response in cirrhotic patients—lifelong surveillance remains mandatory 1, 2
• Avoid NSAIDs completely in patients with ascites, as they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites 3, 5