Address systemic problems along with targeted treatment
Malnutrition is a serious problem for many patients with cirrhosis. Causes range from poor oral intake or malabsorption to ongoing alcohol use, chronic nausea, or early satiety because of compression from ascites. Dental problems that prevent the patient from chewing properly may be a contributing factor, as well.
Regardless of the cause, malnutrition is associated with muscle wasting, hypoalbuminemia, decreased resistance to infections, and variceal bleeding, and addressing it is a key part of treatment. Assess the nutritional status of every patient with cirrhosis, and stress the importance of multivitamin supplementation.21 If dental care is needed, take steps to see that the patient receives it.
Nutritional support, however, should be reserved for severely malnourished patients awaiting transplantation.22
Osteoporosis. Reduced bone formation—the result of vitamin D deficiency, hypoparathyroidism, and hypogonadism—is a well-known complication of end-stage cirrhosis. However, osteopenia may occur in an earlier stage of disease, especially in patients with cholestatic disease and those receiving antiviral therapy. Prescribe bisphosphonates, together with calcium and vitamin D3, to improve bone mineral density.23
Diabetes. The relationship between diabetes and cirrhosis is particularly complex, because diabetes can be both a causal factor and a consequence of cirrhosis. Diabetes is common in patients with NASH, and prevalent among those with hepatitis C and hemochromatosis. Multivariate analyses have found that diabetes has an independent negative effect on the progression of liver disease.24
Diet remains the first-line treatment for hyperglycemia, with metformin as the drug of choice if diet alone is unsuccessful. Sulfonylureas can be used, but require caution to avoid hypoglycemia. Glitazones are a newer alternative, but their value in patients with liver cirrhosis has not been studied. However, the use of any oral antidiabetic agent requires extra caution in patients with cirrhosis, and should be avoided in those with advanced liver disease. Although insulin requires intense self-monitoring of serum glucose levels, it is preferable to oral agents for this patient population.25
Managing complications of cirrhosis
Hospital, home, or long-term care? Whether patients with advanced cirrhosis can be maintained at home or require hospitalization or long-term care is best decided in consultation with patient, family, and other members of the health care team. One helpful tool is the Karnofsky Performance Scale Index (http://www.pennmedicine.org/homecare/hcp/elig_worksheets/Karnofsky-Performance-Status.pdf), which scores patients from 0 to 100 based on their functional impairment.26 (Patients with decompensated liver cirrhosis and limited self-sufficiency typically score <50, indicating that they require home health care, hospice, or institutional care.) Whatever the outcome, the patient may need to be reevaluated as the disease progresses and complications occur.
Ascites, the most common complication of cirrhosis,27 is a primary reason for hospitalization, but may be managed on an outpatient basis, depending on the patient presentation. Determining factors include the presence or absence of portal hypertension, impaired albumin synthesis, decreased plasma oncotic pressure, and sodium retention. Diagnosis is based on physical exam and ultrasonography.
Initial treatment for ascites includes salt restriction28,29 and avoidance of NSAIDs, which promote renal sodium retention, followed by spironolactone (100–400 mg/d). Add furosemide (40-160 mg/d) if the fluid retention does not begin to resolve after 3 to 5 days of treatment. If the condition persists despite maximum tolerable doses of diuretics, large-volume paracentesis to remove transudative fluid (albumin <1 g/dL; serum/ascites albumin gradient >1.1) may be needed. A patient with recurrent or refractory ascites should see a specialist for further evaluation and the possibility of a transjugular intrahepatic portosystemic shunt (TIPS).
Abdominal pain and an ascitic granulocyte count >250/mm3 suggest spontaneous bacterial peritonitis (SBP)—a severe complication of ascites that can result in renal and liver failure. In addition to pain, patients may present with tense ascites and fever, followed by encephalopathy, shock, and increased serum creatinine levels. Hospitalization is required for SBP; therapy includes high-dose albumin and intravenous antibiotics, typically cephalosporin. Long-term prophylaxis with norfloxacin to prevent the recurrence of SBP is indicated.30
If your patient has ascites and is being cared for at home, talk to the patient and his or her family about the importance of a daily weight check. Tell them to contact you if the patient gains more than 4 to 8 lbs within a few days. Frequent electrolyte checks are needed, as well. An albumin infusion is required when serum levels are particularly low, or after large-volume paracentesis.31 Patients with SBP or refractory ascites generally have more advanced disease and a poor prognosis.