Treatment of Cirrhosis

General Management Principles

The American Association for the Study of Liver Diseases recommends that treating the underlying disease is crucial for patients with cirrhotic ascites and should be the first priority 1
Abstinence from alcohol is essential for patients with alcohol-related cirrhosis, as it can result in dramatic improvement in the reversible component of alcoholic liver disease within months 2
Continuous monitoring for complications is needed even after successful treatment of the underlying cause, as the risk of hepatocellular carcinoma remains in patients with cirrhosis 3

The American Association for the Study of Liver Diseases recommends antiviral treatment for patients with Child-Turcotte-Pugh (CTP) class A cirrhosis to decrease the risk of progression to decompensated cirrhosis and development of hepatocellular carcinoma 4
For patients with HBV-related compensated cirrhosis, monotherapy with tenofovir or entecavir is recommended due to their potency and minimal risk of resistance 5, 6
Peginterferon alfa can be used for treating well-compensated cirrhosis in appropriate patients 6

For patients with decompensated cirrhosis due to HBV, entecavir and tenofovir monotherapy are the preferred first-line options 6
Peginterferon alfa is contraindicated in patients with decompensated cirrhosis 6
Patients with CTP class B cirrhosis can be treated with antiviral therapy by experienced specialists with careful monitoring 4
The current standard treatment regimen is contraindicated in patients with CTP class C due to the high risk of severe complications 4

Dietary sodium restriction (≤5 g/day or sodium 2 g/day, 88 mmol/day) is recommended 1
Protein supplementation (1.2-1.5 g/kg/day) is recommended for patients with cirrhotic ascites 1
The primary diuretic for cirrhotic ascites is an aldosterone antagonist (spironolactone), starting at 50-100 mg/day and increasing up to 400 mg/day 1
Furosemide can be used in combination with spironolactone, starting at 20-40 mg/day and increasing up to 160 mg/day 1
For large-volume paracentesis, 6-8 g of albumin infusion per liter of ascites drained is recommended 1

Vasoactive drug therapy (terlipressin, somatostatin, or octreotide) should be initiated as soon as acute variceal bleeding is suspected, before endoscopy 7, 8
Gastroscopy should be performed within 12 hours after admission once hemodynamic stability is achieved 8
Antibiotic prophylaxis is recommended in cirrhotic patients with acute GI bleeding (ceftriaxone 1 g/24h for up to seven days) 7, 8
Transjugular intrahepatic portosystemic shunt (TIPS) should be used as rescue therapy for uncontrolled bleeding 8

In patients with HRS-AKI, after withdrawing diuretics and treating precipitating factors, volume challenge with IV albumin (1 g/kg, maximum 100 g/day) is recommended for 48 hours 9
Vasoconstrictors (terlipressin 0.5-2.0 mg IV q6h or continuous infusion) and albumin (20-40 g/day) are recommended for patients with Stage 2 or greater HRS-AKI 9

Patients with cirrhosis should be screened for HCC with imaging studies (preferably MRI, or CT, ultrasound) every six months 5

Patients with HIV-HBV coinfection have higher risk of progression to cirrhosis and should be monitored closely 5, 6
Renal function monitoring is particularly important in patients with multiple risk factors for renal impairment 6
Growth factors such as recombinant erythromycin or G-CSF can help overcome hematological complications in cirrhotic patients 4

Liver transplantation is the definitive treatment for HRS-AKI in cirrhosis but needs to be considered in the context of multiorgan failure and overall transplant candidacy 9

The American Gastroenterological Association recommends addressing metabolic risk factors, including obesity, for patients with nonalcoholic steatohepatitis 10
The European Association for the Study of the Liver suggests a protein intake of 1.2-1.5 g/kg/day to prevent sarcopenia and protein catabolism, and a caloric intake of 35-40 kcal/kg/day, with 4-6 small meals per day including a night snack to prevent catabolism 11
Avoid long-term protein restriction as it induces protein catabolism, hepatic dysfunction, and sarcopenia, as recommended by the American Association for the Study of Liver Diseases 11

The American Association for the Study of Liver Diseases recommends lactulose as first-line therapy, which reduces mortality and prevents recurrent overt hepatic encephalopathy, and can be given orally or as enema in severe cases 11
Rifaximin can be combined with lactulose as a second-line option, as suggested by the European Association for the Study of the Liver 11

The American Society of Transplantation indicates liver transplantation for decompensated cirrhosis with small hepatocellular carcinoma, severe hepatic encephalopathy not responding to medical treatment, and hepatorenal syndrome in appropriate candidates 12, 11