Child-Pugh classification of the severity of cirrhosis

Point (*)

1

2

3

Total bilirubin, mg/dL (?mol/L)

<2 (<34)

2-3 (34-50)

>3 (>50)

Serum albumin, g/L (?mol/L)

>35 (>507)

28-35 (406-507)

<28 (<406)

INR

<1.7

1.7-2.20

>2.20

Ascites

None

Mild/Moderate (diuretic responsive)

Severe

(diuretic refractory)

Hepatic

encephalopathy

None

Grade I-II

(or suppressed with medication)

Grade III-IV

(or refractory)

Management of hypervolaemic hyponatraemia

1. Fluid restriction: 1000-1500 mL/day (consumption of bouillon allowed ad libitum)

2. If fl uid restriction is ineffective, consider use of oral tolvaptan

a. To be started in hospital at 15 mg/day for 3-5 days, then titrated to 30-60 mg/day until normal s-Na; duration of treatment unknown (efficacy/safety only established in short-term studies (1 month))

b. S-Na should be monitored closely, particularly after initiation, dose modification or if clinical status changes.

c. Rapid increases in s-Na concentration (>8 mmol/day) should be avoided to prevent osmotic demyelisation syndrome

d. Persons may be discharged after s-Na levels are stable and without need to further adjust dose

Management strategy of hepatic encephalopathy (HE)

General management

1. Identify and treat precipitating factor (GI haemorrhage, infection, prerenal azotaemia, constipation, sedatives)

2. Short-term (< 72 hours) protein restriction may be considered if HE is severe

Specific therapy

Lactulose 30 cm³ orally every 1-2 h until bowel evacuation, then adjust to a dosage resulting in 2-3 formed bowel movements per day (usually 15-30 cm³ orally bid).

Lactulose enemas (300 cm³ in 1L of water) in persons who are unable to take it orally. Lactulose can be discontinued once the precipitating factor has resolved.

Management strategy in uncomplicated ascites

General management

• Treat ascites once other complications have been treated
• Avoid NSAIDs
• Norfloxacin prophylaxis (400 mg orally, q.d.) in persons with 1) an ascites protein level of <1.5 mg/dL, 2) impaired renal function (serum creatinine level >1.2 mg/dL, BUN >25 mg/dL) 3) s-Na level <130 mE g/L), or 4) severe liver failure (Child Pugh score >9 points with serum bilirubin level > 3mg/dL)

Specific management

• Salt restriction 1-2 g/day. Liberalie if restriction results in poor food intake
• Large volume paracentesis as initial therapy only in persons with tense ascites
• Administer intravenous albumin (= 6-8 g per litre of ascites removed)

Follow-up and goals

• Adjust diuretic dosage every 4-7 days
• Weigh the person at least weekly and BUN, s-creatinine, and electrolytes measured every 1-2 weeks while adjusting dosage
• Double dosage of diuretics if: Weight loss <2 kg a week and BUN, creatinine and electrolytes are stable
• Halve the dosage of diuretics or discontinue if: Weight loss ≥0.5 kg/day or if there are abnormalities in BUN, creatinine or electrolytes
• Maximum diuretic dosage: spironolactone (400 mg q.d.) and furosemide (160 mg q.d.)

Nutrition of cirrhotic persons

Caloric requirements

• 25-30 Kcal/kg/day of normal body weight

Protein requirements

• Protein restriction is not recommended (see above for exception if HE)

• Type: rich in branched chain (non-aromatic) amino acids
• Some studies support that parental proteins carry less risk of encephalopathy since not converted by colonic bacteria into NH₃

Micronutrients

• Magnesium(Mg) and Zinc (Zn)

Analgesia in persons with hepatic failure

• Acetaminophen can be used; caution on daily dose (max 2 g/day).
• NSAIDs generally avoided, predispose persons with cirrhosis to develop GI bleeding. Persons with decompensated cirrhosis are at risk for NSAID-induced renal insufficiency.

• Opiate analgesics are not contraindicated but must be used with caution in persons with pre-existing hepatic encephalopathy.

Screening for hepatocellular carcinoma

• Ultrasound (US) every 6 months
• Alpha-foetoprotein is a suboptimal surveillance tool because of low sensitivity and specificity
• In case of suspicious lesions on US, perform CT scan (+arterial phase) or dynamic contrast-enhanced MRI
• Confirm diagnosis by fi ne needle aspiration or biopsy should CT scan or MRI be inconclusive

When to refer for liver transplantation?

Best to refer early as disease progresses rapidly

= MELDⁱⁱ score 10-12 (listing at 15)

Decompensated cirrhosis (at least one of the following complications)

• Ascites
• Hepatic encephalopathy
• Variceal bleeding
• Spontaneous bacterial peritonitis
• Hepatorenal syndrome
• Hepatopulmonary syndrome
• Hepatocellular carcinoma

Diagnosis

Consider HRS in a person with cirrhosis and ascites and a creatinine level of >1.5 mg/dL. It is a diagnosis of exclusion. Before making the diagnosis, the following need to be ruled out and treated:

• Sepsis (person needs to be pancultured)
• Volume depletion (haemorrhage, diarrhoea, overdiuresis)
• Vasodilatators
• Organic renal failure (urine sediment; kidney ultrasound)

Diuretics should be discontinued and intravascular volume expanded with intravenous (iv) albumin. If renal dysfunction persists despite above, diagnose HRS.

Recommended therapy

Liver transplant (priority dependent on MELD score). If person is on transplant list. MELD score should be updated daily and communicated to transplant centre.

Alternative (bridging therapy)

Vasoconstrictors

octreotide

100-200 mcg subcutaneously t.i.d

→ Goal to increase mean arterial pressure by 15 mm hg

+ midodrine

5-15 mg orally tid

or terlipressin

0.5-2.0 mg iv every 4-6 hours

and iv albumin (both for at least 7 days

50-100 g iv qd