Copyright ©2011 Baishideng Publishing Group Co.
World J Gastroenterol. May 14, 2011; 17(18): 2273-2282
Published online May 14, 2011. doi: 10.3748/wjg.v17.i18.2273
Table 1 Diagnostic tests, suggested etiology, and current treatment for the most frequent forms of liver cirrhosis in adult patients
Abnormal test(s)EtiologyTreatment
γGT (high), MCV (high)AlcoholAbstinence
HBsAg, HBV-DNA, HBc-IgM, HDV-RNA (positivity)HBV + Delta virus infectionInterferon α-2b, nucleoside (Lamivudine, Telbivudine, Entecavir) and nucleotide (Adefovir, Tenofovir) analogues
HCV-RNA (positivity)HCV infectionInterferon plus ribavirin
γGT (high), alkaline phosphatase (high), AMA (positivity)Primary biliary cirrhosisUrsodeoxycholate
ANA, ASMA, LKM (positivity)Autoimmune hepatitisPrednisone, azathioprine
Ferritin (high), transferring saturation index (> 45%), liver iron content (high), HFE gene mutation for hereditary hemochromatosis (C282Y, H63D)HemochromatosisPhlebotomy, deferoxamine
Ceruloplasmin (low), serum (low) and 24 h urine copper excretion (high)Wilson’s diseaseD-penicillamine, zinc
HDL-cholesterol (low), glucose (high), triglycerides (high)NAFLD/NASHLow caloric diet, exercise, drugs lowering insulin-resistance
Table 2 Child-Pugh scoring system for liver cirrhosis and related indication priority for transplantation[20]
Bilirubin (mg/dL)< 22-3> 3
Prothrombin time (INR)< 4 sec. (< 1.7)4-6 sec. (1.7-2.3)> 6 sec. (> 2.3)
Albumin (g/dL)> 3.53.5-2.8< 2.8
Table 3 Current indications and contraindications to orthotopic liver transplantation in adult patients with liver cirrhosis
Advanced chronic liver failureRelative
Child-Pugh score > 7HIV seropositivity
Qualifying MELD scoreMethadone dependence
Stage 3 hepatocellular carcinoma
Acute liver failureAbsolute
Drug, toxins or virus induced fulminant hepatitisExtrahepatic malignant disease
Severe, uncontrolled systemic infection
Multiorgan failure
Advanced cardiopulmonary disease
Active substance abuse
No alternative available treatment
No absolute contraindications
Willingness to comply with follow-up care and family assistance
Table 4 Standard objectives for an efficient out clinic care of cirrhotic patients
1 Early diagnosis of chronic liver disease. Identification of etiology
2   Identification of patients with chronic liver disease at risk of cirrhosis
3 Evaluation of patient’s general health status
4 Act on etiologic factors and on factors favoring disease progression. Identify treatment end-points and place the patient within his family and social setting
5 Promote family and cohabitants’ participation to primary prevention for infective forms (health education), secondary prevention for inherited or metabolic disorders, support and surveillance for toxic forms (alcohol)
6 Suggest health-dietetic measures and therapeutic remedies
7 Check parameters of effectiveness and control side effects of specific treatments (antiviral, phlebotomy, immune-depressants, β-blockers, etc.)
8 Identify and treat associated conditions (diabetes, osteoporosis, malnutrition, etc.)
9 Avoid administration of hepatotoxic drugs, drugs promoting renal sodium retention and central nervous system depressants
10 Promote vaccination against flu and pneumonia, including transplanted patients, and against hepatitis A and B virus
11  Supervise for complications by promoting clinical, biochemical and instrumental follow-up
12  Assist specialists in identifying candidates for liver transplantation
13  Assist the patient requiring legal problems
Table 5 Features of home assistance in patients with liver cirrhosis
Decreased number of hospitalization and re-admissions
Decreased costs of treatments
Assist the patient within his familiar comfort
Criteria of eligibility
Identification of a clinical status allowing home stay
Identification of priority criteria
Presence of a valid family support or of an active aid system
Selection criteria
Use the Karnofsky Performance Status1 for patients with decompensated liver cirrhosis and limited self-sufficiency (set to < 50%)
Table 6 Key messages for best management of cirrhotic patients
1 A compensated liver cirrhosis is suspected with abnormal liver function tests, low platelets count, and prolonged prothrombin time[63]III
2 Ultrasonography is a reliable, non-invasive, fast, and cost-effective test working as a first-line tool for diagnosing liver cirrhosis[64]II-III
3 Child-Pugh and MELD scores assess the prognosis of liver cirrhosis[19,20]I
4 First-line treatment of patients with cirrhotic ascites includes diuretics and sodium restriction. Anti-aldosterone drugs are given with loop diuretics to increase diuretic response or when renal perfusion is impaired. Dietary salt intake should be restricted to approximately 88 mmol/day (2000 mg/d). Marked salt restriction can expose the risk of hyponatremia[32,37]I
5 Removal of less than 5 liters of fluid does not appear to have a hemodynamic consequence. For larger paracentesis, albumin (6 to 8 g/L of fluid removed) can be administered. Albumin is indicated in patients with PBS to prevent renal failure, and in patients with hepatorenal syndrome. Albumin can be also used to treat refractory ascites. Its infusion at home is safe and cost-effective[37,65]II
6 β-blockers (e.g. propranolol or nadolol) are recommended for prophylaxis of variceal bleeding at a dosage titrated to a 25 percent reduction in pulse rate[66]I
7 Liver transplantation is the only definitive care for patients with major complications (ascites, bleeding, HCC) and/or MELD above 13[1]I
8 Osteoporosis is an important systemic complication of end-stage liver cirrhosis. Management includes vitamin D and bisphosphonates[53]II
9 Malnutrition is a negative and independent predictor of survival in patients with liver cirrhosis[67]II
10 An integrated assistance of patients with liver cirrhosis has a better outcome than the management by generalists/specialists alone[61]II