Management of Chronic Liver Damage

Initial Approach and Severity Assessment

The management of chronic liver damage should begin with the elimination of the underlying etiological factor (alcohol, virus, drugs, metabolic disorders) and a systematic assessment of the severity of liver disease using biochemical markers, imaging studies, and non-invasive methods of fibrosis assessment, as recommended by the European Association for the Study of the Liver 1
Initial evaluation should include biochemical markers such as AST, ALT, GGT, alkaline phosphatase, prothrombin time, serum albumin, and platelet count, according to the American Association for the Study of Liver Diseases 2
Ultrasound of the liver should be performed to evaluate liver architecture, surface irregularity, caudate lobe hypertrophy, and indirect signs of portal hypertension, as suggested by the American College of Gastroenterology 3
Transient elastography (FibroScan) values ≥15 kPa strongly suggest cirrhosis or advanced chronic liver disease, as indicated by the European Association for the Study of the Liver 3
Non-invasive fibrosis scores, such as FIB-4, using age, ALT, AST, and platelets, with values >2.67 indicating high risk of advanced fibrosis, are recommended by the American Association for the Study of Liver Diseases 4

Patients with chronic hepatitis B and HBV DNA >2000 IU/ml and elevated ALT should receive nucleoside analogs as first-line treatment, as recommended by the American Association for the Study of Liver Diseases 5
Direct-acting antivirals improve liver function and portal hypertension in patients with hepatitis C, although beneficial effects are not universal, according to the European Association for the Study of the Liver 1
Coinfections with HDV, HCV, and/or HIV should be systematically ruled out, as suggested by the American Association for the Study of Liver Diseases 2

Paracentesis of large volume is indicated in refractory ascites, with albumin replacement to prevent circulatory dysfunction, as recommended by the European Association for the Study of the Liver 1
Non-selective beta-blockers (carvedilol or propranolol) reduce the risk of decompensation or death in patients with portal hypertension, according to the American College of Gastroenterology
Rifaximin, a non-absorbable antibiotic, is used for secondary prevention of hepatic encephalopathy, as indicated by the American Association for the Study of Liver Diseases 8
Lactulosa reduces mortality and recurrence of hepatic encephalopathy in patients with cirrhosis, as shown in a meta-analysis of 705 patients, although the strength of evidence is moderate 8

ACLF is defined by acute decompensation of cirrhosis with failure of one or more extrahepatic organs and high short-term mortality (30-50% at 28 days), as defined by the European Association for the Study of the Liver 10
Diagnostic criteria require three elements: liver failure (elevated bilirubin and INR) in chronic liver disease with or without cirrhosis, acute onset with rapid clinical deterioration, and presence of at least one extrahepatic organ failure (neurological, circulatory, respiratory, or renal), as recommended by the American Association for the Study of Liver Diseases 10
Management in intensive care includes support of organ failures, control of glucose levels, and empirical antibiotics, as suggested by the European Society of Intensive Care Medicine 9
Contact with a liver transplant center is essential for selected patients, as recommended by the American Association for the Study of Liver Diseases 11

Ultrasound of the liver every 6 months, with or without alpha-fetoprotein, is recommended for patients with cirrhosis or advanced fibrosis, as indicated by the American Association for the Study of Liver Diseases 1
Incidence of hepatocellular carcinoma is 1-4% per year in patients with cirrhosis, although the strength of evidence for this estimate is low

Patients with advanced fibrosis/cirrhosis should continue hepatological follow-up even after successful antiviral therapy, decrease in non-invasive fibrosis tests, or measurement of liver stiffness, as recommended by the European Association for the Study of the Liver 3
Liver enzymes should be repeated every 3-6 months in patients without immediate referral criteria, as suggested by the American Association for the Study of Liver Diseases 4
Referral to hepatology is recommended when extended etiological screening is negative without identifiable risk factors for MASLD, FIB-4 >2.67, or presence of cirrhosis complications (ascites, encephalopathy, variceal bleeding), as indicated by the American Association for the Study of Liver Diseases 4
Patient and caregiver education should include effects and side effects of medications, early signs of recurrent encephalopathy, and measures to prevent constipation, as recommended by the American Association for the Study of Liver Diseases 8