What blood work is required for a patient with cirrhosis?

Required Blood Work for Patients with Cirrhosis

All patients with cirrhosis require a comprehensive hepatic function panel including bilirubin, AST, ALT, alkaline phosphatase, albumin, PT/INR, complete blood count with platelet count, and renal function tests (creatinine and BUN) for both initial diagnosis and ongoing management. 1

Initial Diagnostic Laboratory Panel

When cirrhosis is suspected or newly diagnosed, obtain the following tests:

Core Hepatic Function Tests

• Bilirubin (total and conjugated): Elevated conjugated bilirubin indicates advanced disease or biliary obstruction 1
• AST and ALT: Typically elevated in active liver injury, with AST/ALT ratio often >1 in cirrhosis 1
• Alkaline phosphatase: May be elevated, particularly in cholestatic liver disease 1
• GGT: Useful for detecting hepatobiliary involvement and calculating fibrosis indices 1
• Albumin: Decreased levels indicate impaired synthetic function and are critical for Child-Pugh scoring 1
• PT/INR: Prolonged values indicate impaired hepatic synthetic function and are essential for both Child-Pugh and MELD scoring 1, 2

Hematologic Assessment

• Complete blood count with differential: Essential for detecting thrombocytopenia, which suggests portal hypertension and serves as a surrogate marker for advanced disease 1
• Platelet count specifically: Critical for calculating fibrosis indices like APRI and FIB-4 1

Renal Function

• Creatinine and BUN: Essential for MELD score calculation and detecting hepatorenal syndrome 1, 3
• Creatinine is an established prognostic marker in liver disease 1

Etiologic Workup

Once cirrhosis is confirmed, determine the underlying cause with these tests:

• Hepatitis B panel and hepatitis C antibody: Required in all cases, with viral load confirmation if positive to guide antiviral therapy 1
• Ferritin and transferrin saturation: Screen for hemochromatosis 1
• Autoimmune markers: If etiology remains unclear 1
• Alpha-1 antitrypsin level: Screen for alpha-1 antitrypsin deficiency 1
• Ceruloplasmin: Consider for Wilson disease, particularly in younger patients 1

Routine Monitoring Schedule

For Stable Compensated Cirrhosis

Perform the following tests every 6 months: 1, 4

• Child-Pugh score components (bilirubin, albumin, PT/INR, plus clinical assessment of ascites and encephalopathy)
• MELD score components (bilirubin, INR, creatinine, sodium for MELD-Na)
• Albumin-bilirubin grade
• Complete blood count
• Comprehensive metabolic panel

For Decompensated Cirrhosis or Active Complications

Increase monitoring frequency to every 1-3 months with the same laboratory panel 1

Special Circumstances Requiring Additional Testing

When Ascites Develops or is Present

Perform diagnostic paracentesis immediately and obtain: 1

• Ascitic fluid cell count with differential
• Ascitic fluid total protein
• Serum-ascites albumin gradient (SAAG)
• Ascitic fluid culture (inoculate 10 mL into blood culture bottles at bedside)

Critical pitfall to avoid: Diagnostic paracentesis should be performed immediately without delay to rule out spontaneous bacterial peritonitis in patients with ascites on hospital admission 1

When Assessing for DIC vs Adaptive Coagulation

In hospitalized patients with acute illness, add: 2

• D-dimer: Markedly elevated levels may indicate coagulation activation or portal vein thrombosis risk 2
• Fibrinogen level: Required for DIC scoring, which may improve prediction of 90-day mortality over MELD score alone 2
• Factor VIII and von Willebrand factor: Low and/or declining levels serve as confirmatory tests of consumptive coagulopathy that should not occur in adaptive changes of liver disease 2

The routine INR and platelet count provide only 2 of 4 measurements needed to evaluate for DIC, making additional testing necessary in acutely ill patients 2

Pre-Procedure Coagulation Assessment

Despite shortcomings, platelet count and fibrinogen level remain the standard of care assessment before procedures when coagulation evaluation is indicated 2

However, several common procedures do not routinely require coagulation assessment: 2

• Diagnostic and therapeutic paracentesis
• Common forms of thoracentesis
• Upper endoscopy to screen for and band esophageal varices
• Diagnostic (but not therapeutic) colonoscopy

Important caveat: This does not apply to pharmacologically anticoagulated patients or those with renal failure, who may be at increased risk for bleeding 2

Critical Clinical Pitfalls to Avoid

• Do not wait for high thresholds: Avoid delaying evaluation when liver enzymes are only mildly elevated; use age and sex-normative values rather than waiting for values >1.5-2× upper limit of normal 1
• Persistent abnormalities warrant evaluation: Even mildly elevated values persisting over 3-6 months require further workup 1
• Screen during clinical stability: Recognize that transient elevations may occur; perform screening when patients are clinically stable 1
• INR is problematic in cirrhosis: The INR was designed for warfarin monitoring, not for assessing bleeding risk in liver disease, and commonly utilized thresholds for INR correction are not supported by evidence 2

Alcohol-Related Cirrhosis Monitoring

For patients with alcohol-related cirrhosis, add: 1

• Mean corpuscular volume (MCV) and GGT: These markers can indicate ongoing alcohol consumption
• Regular assessment of alcohol use with referral to addiction services as needed 1