Management of complications of cirrhosis in patients awaiting liver transplantation

Abstract

Up to the late 1970’s patients with decompensated cirrhosis in form of ascites, hepatorenal syndrome (HRS), hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), gastroesophageal variceal bleeding and/or hepatocellular carcinoma had a grim prognosis and therapy was mainly symptomatic and palliative. Introduction of orthotopic liver transplantation (OLT) more than 20 years ago as an established therapy for decompensated liver disease significantly changed the outcome of patients with advanced cirrhosis [1]. Although OLT was a major step in management of decompensated cirrhosis, it took at least a decade to realize that influencing the pre-transplant status of patients would translate into better post-transplant outcomes [2,3]. Since listing criteria for OLT in cirrhosis include complications such as ascites, HRS, variceal bleeding, hepatic encephalopathy, SBP, among others, optimal therapy of these is warranted in order to assure that patients reach OLT and have a good post-transplant outcome. The goals of pre-operative care include the appropriate management of decompensated liver disease with interventions such as diuretics for ascites, antibiotic prophylaxis against SBP, the use of beta-blockers or banding for the primary or secondary prophylaxis of variceal bleeding, endoscopic variceal banding plus vasoconstrictors for active variceal bleeding, use of oral synthetic disaccharides such as lactulose to prevent recurrences of hepatic encephalopathy, therapeutic paracentesis with albumin for refractory ascites and vasoconstrictors with albumin for HRS. Because the complications of cirrhosis can be life threatening, a patient’s clinical status while listed must be assessed very frequently. Standard medical care of these patients should include screening for colorectal, prostate, breast, and cervical cancer. Smoking cessation is of key importance. If the patient has a history of alcoholism proper measures to ensure abstinence such as an alcohol rehabilitation program must be offered. In addition patients should be vaccinated against hepatitis A and B. This article will focus on the management of ascites, dilutional hyponatremia, HRS, SBP, hepatic encephalopathy, and variceal bleeding in patients awaiting OLT. Hepatocellular carcinoma, commonly encountered in compensated and decompensated cirrhotics should also be managed aggressively, however, this topic is beyond the scope of this review and has been recently reviewed elsewhere [4].