What is the management approach for a patient with acute decompensated liver cirrhosis?

Management of Acute Decompensated Liver Cirrhosis

Patients with acute decompensated liver cirrhosis require immediate resuscitation, early identification and treatment of precipitating factors (particularly infections and bleeding), organ support in intermediate or intensive care settings, and urgent evaluation for liver transplantation. 1

Immediate Resuscitation and Stabilization

Assess airway, breathing, and circulation immediately with prompt volume replacement using crystalloids to restore hemodynamic stability. 1

• Place at least two large-bore intravenous catheters to facilitate rapid volume expansion 2
• Consider endotracheal intubation for airway protection in patients with massive bleeding or hepatic encephalopathy 2
• Implement a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL (target range 7-9 g/dL) to avoid increasing portal pressure and rebleeding risk 1, 2

Immediately discontinue diuretics, beta-blockers, vasodilators, nephrotoxic drugs (NSAIDs, aminoglycosides), and other hypotensive medications during acute decompensation. 1

Early Identification and Treatment of Precipitating Factors

Screen for and treat infections promptly, as they are present in over 50% of patients with acute decompensation and are the most common precipitating factor for acute-on-chronic liver failure (ACLF). 1

• Initiate antibiotic prophylaxis immediately with ceftriaxone 1g IV daily for up to 7 days in all patients with decompensated cirrhosis 1, 2
• Ceftriaxone is preferred over quinolones in advanced cirrhosis, patients on quinolone prophylaxis, or settings with high quinolone resistance 1, 2

For suspected variceal bleeding, start vasoactive drugs (terlipressin, somatostatin, or octreotide) immediately upon suspicion, even before endoscopic confirmation. 1, 2

• Continue vasoactive therapy for 3-5 days after endoscopic treatment 2
• Perform upper endoscopy within 12 hours once hemodynamic stability is achieved 1, 2
• Pre-endoscopy erythromycin (250 mg IV, 30-120 minutes before) improves visibility if no contraindications exist 2
• Endoscopic band ligation is the preferred treatment for esophageal varices 1, 2

Organ Support and Monitoring

Patients should be treated in intermediate care or intensive care settings with frequent monitoring of liver, kidney, brain, lung, coagulation, and circulation throughout hospitalization, as ACLF is a dynamic condition. 3

Management of Ascites

• Perform therapeutic paracentesis with albumin infusion (1 g/kg body weight, maximum 100 g) in patients with tense ascites 1
• Monitor for hepatic encephalopathy and renal function deterioration during ascites management 1

Management of Hepatic Encephalopathy

• Use lactulose or lactitol when encephalopathy develops 1, 2
• Consider oral non-absorbable disaccharides for prevention 1

Management of Acute Kidney Injury (AKI)

• Administer 20% albumin solution (1 g/kg body weight, maximum 100 g) for two consecutive days in AKI stage >1A with no obvious cause 1
• Preserve renal function with adequate replacement of fluids and electrolytes 1
• Renal replacement therapy (RRT) should not be used as stand-alone therapy unless the patient is a liver transplant candidate 3
• Continuous RRT is preferable to intermittent RRT in hemodynamically unstable patients 3

Specific Antiviral Therapy for HBV-Related Decompensation

Administer nucleoside analogues (tenofovir or entecavir) as early as possible in patients with ACLF due to HBV infection, as this is the only specific therapy proven to improve survival in ACLF. 3

• The licensed entecavir dose for decompensated cirrhosis is 1 mg (instead of 0.5 mg) once daily 3
• Both tenofovir and entecavir are effective and generally safe in decompensated patients 3
• Monitor closely for lactic acidosis in patients with advanced decompensation (MELD score >20) on entecavir 3
• Adjust doses of all nucleoside analogues in patients with creatinine clearance <50 ml/min 3
• Continue treatment indefinitely in cirrhotic patients with decompensation 3

Prognostic Assessment

Use Child-Pugh score for initial stratification (scores 7-10 indicate decompensated disease), MELD/MELD-Na for transplant prioritization, and CLIF-C ACLF score for better prognostic accuracy in ACLF. 1

• Acute decompensation can progress through stages: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-ACLF, and ACLF, with vastly different mortality risks 4, 5
• ACLF is characterized by organ failure(s) and high short-term mortality 3, 1

Liver Transplantation Evaluation

Early referral of patients with ACLF to liver transplant centers for immediate evaluation is recommended. 3

• All patients with hepatorenal syndrome-AKI who are potential transplant candidates should be referred without delay 3
• Patients with four or more organ failures after one week of adequate intensive treatment who are not transplant candidates should have intensive care support withdrawn due to futility 3
• Consider simultaneous liver-kidney transplant in patients with prolonged pretransplant RRT >6 weeks 3

Rescue Therapies for Treatment Failure

Transjugular intrahepatic portosystemic shunt (TIPS) is the rescue therapy of choice for persistent bleeding or early rebleeding. 1, 2

• Early pre-emptive covered TIPS can be considered in high-risk patients (Child-Pugh class C with score <14 or selected Child-Pugh class B patients with active bleeding) 2
• Balloon tamponade can be used as a temporary bridge in uncontrolled bleeding while awaiting definitive treatment 1, 2

Therapies NOT Recommended

Extracorporeal liver support systems do not improve survival in ACLF and should not be recommended. 3

Granulocyte colony-stimulating factor (G-CSF) cannot be recommended at present despite promising results. 3

Interferon (PEG-IFN) is contraindicated in decompensated cirrhosis as it may increase risk of bacteremic infection and hepatic decompensation. 3

Secondary Prevention

Initiate secondary prophylaxis with non-selective beta-blockers and/or endoscopic band ligation once bleeding is controlled. 1, 2

• Use beta-blockers with caution in patients with severe or refractory ascites 1, 2
• Discontinue beta-blockers if systolic blood pressure falls below 90 mmHg 1, 2
• Address underlying causes of cirrhosis (alcohol cessation, antiviral therapy for HBV/HCV) 1
• Screen for gastroesophageal varices with endoscopy if not previously diagnosed 1
• Repeat endoscopy yearly in patients without varices if the etiological factor persists 1

Critical Pitfalls to Avoid

• Do not use lamivudine in patients with cirrhosis due to high resistance risk 3
• Avoid large volume paracentesis without albumin replacement 1
• Do not continue beta-blockers during acute decompensation or in patients with refractory ascites 1
• Monitor closely for development of ACLF, which requires escalation of care and transplant evaluation 3, 1
• Maintain high suspicion for infections even without obvious clinical signs, as they drive progression to ACLF 1