Management of Decompensated Cirrhosis

Primary Treatment Strategy: Address the Underlying Cause

The American Association for the Study of Liver Diseases recommends that etiological treatment must be initiated immediately, as this is associated with decreased risk of further decompensation and increased survival, though effectiveness varies based on disease severity at treatment initiation 1, 2, 3
The European Association for the Study of the Liver suggests that hepatitis B treatment should be initiated with entecavir (1 mg daily for decompensated patients) or tenofovir monotherapy regardless of HBV DNA level, as these agents have potent antiviral efficacy and high genetic barrier to resistance 4, 5

The American Association for the Study of Liver Diseases recommends that first-line treatment consists of sodium restriction plus spironolactone with or without furosemide 6
Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L 6

The European Association for the Study of the Liver suggests that lactulose is first-line therapy, reducing mortality and recurrent overt hepatic encephalopathy 7, 8

The American Association for the Study of Liver Diseases recommends that vasoactive drugs should be initiated immediately upon suspicion of variceal bleeding, even before endoscopic confirmation 6
Antibiotic prophylaxis is mandatory, using ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings; use oral norfloxacin 400 mg twice daily in remaining patients 6, 7

The European Association for the Study of the Liver suggests that norfloxacin prophylaxis reduces risk of SBP and hepatorenal syndrome, though use is limited by potential for resistant bacteria 2, 8

The American Association for the Study of Liver Diseases recommends that statins may reduce portal hypertension and improve survival through pleiotropic effects, though validation studies are needed 2, 8
Propranolol in responders decreases risk of ascites, hepatorenal syndrome, SBP, and hepatic encephalopathy beyond variceal bleeding prevention 2, 7

The European Association for the Study of the Liver suggests that early referral for liver transplantation evaluation is essential for appropriate candidates, as decompensation significantly worsens prognosis 8, 7
Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation 7