Liver Cirrhosis: Management

Management of PLWH with cirrhosis should be done in collaboration with experts in liver diseases. More general management guidance is described below

In end-stage liver disease (ESLD), use of EFV may increase risk of CNS symptoms

ART, if otherwise indicated, also provides net benefit to cirrhotic persons. See Diagnosis Management of Hepatorenal Syndrome (HRS)

Management

Fluid restriction: 1000-1500 mL/day (consumption of bouillon allowed ad libitum)
If fluid restriction is ineffective, consider use of oral tolvaptan

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))
S-Na should be monitored closely, particularly after initiation, dose modification or if clinical status changes
Rapid increases in s-Na concentration (> 8 mmol/day) should be avoided to prevent osmotic demyelination syndrome
Persons may be discharged after s-Na levels are stable and without need to further adjust dose

General management

Identify and treat precipitating factor (GI haemorrhage, infection, pre-renal azotaemia, constipation, sedatives)
Short-term (< 72h) protein restriction may be considered if HE is severe

Specific therapy

Lactulose 30 cm³ po every 1-2h until bowel evacuation, then adjust to a dosage resulting in 2-3 formed bowel movements per day (usually 15-30 cm³ po bid)
Lactulose enemas (300 cm³ in 1L of water) in PLWH who are unable to take it po or lactulose can be discontinued once the precipitating factor has resolved

Treat ascites once other complications have been treated
Avoid NSAIDs
Norfloxacin prophylaxis (400 mg po qd) 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 < 130mE g/L, or
4. severe liver failure (Child Pugh score > 9 points with s-bilirubin level > 3 mg/dL)

Salt restriction: 1-2 g/day. Liberalise if restriction results in poor food intake
Large volume paracentesis as initial therapy only in patients with tense ascites
Administer iv albumin (= 6-8 g/L ascites removed)

Adjust diuretic dosage every 4-7 days
Weigh persons 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 qd) and furosemide (160 mg qd)

Protein restriction is not recommended (may be considered in encephalitic patients < 72 hours, especially if HE is severe)
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

Acetaminophen can be used; caution on daily dose (max 2 g/day)
NSAIDs generally avoided; predisposes 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 preexisting hepatic encephalopathy

HepatoCellular Carcinoma (HCC) screening is indicated in all cirrhotic HBV or HCV co-infected PLWH (even if HCV infection has been cured and HBV replication is medically suppressed) in a setting where treatment for HCC is available
- Although the cost-effectiveness of HCC screening in PLWH with F3 fibrosis is uncertain, surveillance may be considered based on an individual risk assessment, https://easl.eu/publication/easl-clinical-practice-guidelines-management-of-hepatocellular-carcinoma/
In HBV-positive non-cirrhotics, HCC screening should follow current EASL guidelines. Risk factors for HCC in this population include family history of HCC, ethnicity (Asians, Africans), HDV and age > 45 years. EASL guidelines propose using the PAGE-B score in Caucasians to assess the HCC risk, however this score has not been validated in PLWH, see Assessment of PLWH at Initial & Subsequent Visits, Cancer: Screening Methods, and Clinical Management and Treatment of Viral Hepatitis Co-infections in PLWH. Table on fibrosis cut-offs, see Cut-off Values of Non-invasive Tests for the Detection of Significant Fibrosis and Cirrhosis
Ultrasound (US), with or without AFP, every 6 months. Alpha- foetoprotein (AFP) should not be used alone.AFP is a suboptimal surveillance tool because of low sensitivity and specificity

Best to refer early as disease progresses rapidly, see Solid Organ Transplantation (SOT)

= MELD score 10-12 (listing at 15)
- Unit for both S-creatinine and S-bilirubin is mg/dL
- MELD Score = 10 (0,957 Ln (serum creatinine (mg/dL)) + 0.378 Ln (total bilirubin (mg/dL)) + 1.12 Ln (INR) + 0.643}. See, http://www.mdcalc.com/meld-score-model-for-end-stage-liver-disease-12-and-older/