“Stages of Cirrhosis” From The Veterans Administration

Today, I review and embed Stages of Cirrhosis from The U.S. Department of Veterans Affairs.

All that follows is from the above resource.

Stages of Cirrhosis

Appropriate timing of the initial referral for transplant evaluation is critical for optimal care of patient with cirrhosis.

Key concepts

  • Cirrhosis is the end stage of any chronic liver disease
  • There are 2 clinical stages of cirrhosis: compensated and decompensated
  • The diagnosis of cirrhosis can be made by clinical, laboratory, imaging, or liver stiffness findings
  • For compensated cirrhosis patients, non-invasive parameters all may be normal and liver biopsy would be required for diagnosis
  • Patients with compensated cirrhosis are asymptomatic and overall have median survival times of > 12 years
  • Patients with decompensated cirrhosis have had at least one complication including ascites, jaundice, variceal hemorrhage or hepatic encephalopathy, and overall they have median survival times of 2 years

Key recommendations

  • Management of patients with any chronic liver disease should include regular assessments for the development of cirrhosis
  • Clinicians should not rule out the presence of compensated cirrhosis on the basis of normal lab or imaging findings; liver biopsy may be necessary for diagnosis
  • The care of patients with compensated cirrhosis should be aimed at the prevention of decompensation
  • Clinicians should recognize decompensated cirrhosis based on overt history, in conjunction with physical and laboratory findings
  • It is critical to understand that decompensating events place patients at higher risk of further complications and death

Stages of Cirrhosis

  • There are 2 stages of cirrhosis: compensated cirrhosis and decompensated cirrhosis (clinical stages)
  • The stages are dynamic and progressive, but there is potential reversibility from the decompensated to compensated stage
  • Compensated cirrhosis is the asymptomatic stage
    • Compensated patients do not have ascites, variceal hemorrhage, hepatic encephalopathy, or jaundice
    • Median survival time of patients with compensated cirrhosis is > 12 years
    • Subpopulations can be identified based on the presence or absence of varices
    • Presence of varices is the key prognostic factor for compensated patients, and indicates higher likelihood of decompensation
  • Decompensated cirrhosis is the symptomatic stage
    • Decompensated cirrhosis is characterized by the presence or development of overt complications: ascites, jaundice, variceal hemorrhage, or hepatic encephalopathy
    • Median survival time of patients with decompensated cirrhosis is approximately 2 years
    • Subpopulations can be identified based on type or number of decompensating events
    • The MELD-Na score is the best predictor of death in patients with decompensated cirrhosis
    • Decompensation may improve and can regress to a compensated stage if the etiology of the liver disease is resolved (eg, alcohol abstinence)

Making the Diagnosis of Compen

sated vs. Decompensated Cirrhosis

  • Cirrhosis can be diagnosed with clinical, laboratory, radiologic, elastographic, or biopsy findings (see Diagnosis of Cirrhosis for details)
  • The diagnosis of compensated cirrhosis is more challenging since patients may lack clinical, laboratory, and radiologic findings and may require biopsy for diagnosis
  • The diagnosis of decompensated cirrhosis is easier as the patient history, physical exam, and laboratory findings are usually more evident

Child-Turcotte-Pugh score

  • The Child-Turcotte-Pugh (CTP) score is used as a prognostic scoring system in cirrhosis based on 2 clinical and 3 laboratory parameters:
    • Ascites: none (1 point); diuretic-sensitive or mild/moderate (2 points); diuretic-refractory or tense (3 points)
    • Encephalopathy: none (1 point); episodic or overt grade 2 (2 points); recurrent/chronic or grade 3-4 (3 points)
    • Albumin in g/dL: > 3.5 (1 point); 3.4-2.8 (2 points); < 2.8 (3 points)
    • Bilirubin in mg/dL: < 2 (1 point); 2-3 (2 points); > 3 (3 points)
    • INR: < 1.7 (1 point); 1.7-2.3 (2 points); > 2.3 (3 points)
  • In the original scoring system, nutritional status (normal, moderately altered, malnourished) was used instead of INR, which reflects the importance of sarcopenia in cirrhosis
  • CTP A patients (5-6 points) are mostly patients with compensated cirrhosis
    CTP B patients (7-9 points) are mostly decompensated but decompensation is “early”
    CTP C patients (10-15 points) are decompensated (late or “further” decompensation)

Primary Goals in Management of Compensated Cirrhosis

  • Treatment of the etiology of the underlying liver disease, for example:
    • Antiviral treatment of HCV or HBV
    • Abstinence from alcohol
  • Screening for varices
    • Prevention of first variceal hemorrhage
  • Screening for hepatocellular carcinoma
    • Screening should continue indefinitely once cirrhosis is diagnosed and even after removal of etiological factor
    • No difference in recommendations for compensated or decompensated patients
  • Prevention of decompensation
    • Alcohol use: complete abstinence
    • Obesity: management
    • Hepatotoxicity from drugs: careful dosing and selection of medications
    • NSAIDs: avoidance
    • Acute injury by viruses: appropriate vaccinations
    • Dyslipidemia: Do NOT avoid statins
    • Diabetes mellitus: optimize control

Primary Goals in Management of Decompensated Cirrhosis

  • Treatment of etiology of the underlying liver disease
    • Antiviral treatment of HCV or HBV is more complicated
    • Abstinence from alcohol
  • Screening for varices (if no history of variceal hemorrhage)
    • Prevention of first variceal hemorrhage
  • Screening for hepatocellular carcinoma
    • Screening should continue indefinitely, even with regression to compensated stage
    • No difference in recommendations for compensated or decompensated patients
  • Symptomatic management of complications
    • Ascites (diuretics → large-volume paracentesis → transjugular intrahepatic portosystemic shunt (TIPS), if refractory
    • Encephalopathy (lactulose → rifaximin, if recurrent)
    • Prevention of further decompensation and death
    • Prevention of recurrent variceal hemorrhage: beta-blockers + ligation, TIPS if recurrent
      • Alcohol use: complete abstinence
      • Obesity: management
      • Hepatotoxicity from drugs: careful dosing and selection of medications
      • Acute injury by viruses: appropriate vaccinations
      • Management of volume status
      • Vasodilators
      • NSAIDs: avoidance
      • Dyslipidemia: Do NOT avoid statins (but use lower dosages)
      • Diabetes mellitus: optimize control
    • Calculate MELD-Na score every 3-6 months

Refer for liver transplant evaluation when appropriate (see When to Refer for Transplant for details)

 

 

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