Cirrhosis Assessment and Recommendations

***ASSESSMENT/SUMMARY***
- Etiology: [text name="variable_1" default=""]
- [select name="variable_2" value="Compensated | Decompensated"]disease
- Complications of portal hypertension:
[checklist name="variable_3" value="Ascites|Hepatic/Porstosystemic Encephalopathy (HE/PSE)|Esophageal Varices|Gastric Varices|Hepatocellular Carcinoma (HCC)|Coagulopathy|Hepatorenal Syndrome (HRS)|Hepatopulmonary Syndrome (HPS)"]

Mortality Scores: [link url="https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld" memo="MELD 3.0 Score"] / [link url="https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality" memo="Child Pugh Score"]
- MELD 3.0 Score: [text name="variable_4" default=""]
- Child-Pugh Score: [text name="variable_5" default=""]

***RECOMMENDATIONS:***
Chronic liver disease workup:
[checklist name="variable_5" value="HBsAg, HBsAb, HCV ab, HAV IgG (for vaccination purposes)|Reflex testing for HBV DNA PCR and/or HCV RNA PCR if initial screens are positive|HIV|HDV Ab w/ HDV RNA PCR if positive in those w/ +HBsAg + severe hepatitis|HEV IgM & IgG w/ HEV RNA PCR if positive in those from endemic regions|Serologies and PCR for nonhepatotropic viruses including cytomegalovirus (CMV), herpes simplex virus (HSV), Epstein-Barr virus (EBV), varicella-zoster virus (VZV), human herpesvirus 6 (HHV-6), and nonherpes viruses including adenovirus, Dengue virus, Chikungunya virus, Ebola virus, and influenza virus based on clinical suspicion|ANA, ASMA, AMA, anti-LKM, c-ANCA, quantitative immunoglobulins|Iron studies (iron, ferritin, TIBC, transferrin)|A1AT and ceruloplasmin levels"]

Hepatic Encephalopathy (HE) / Portosystemic Encephalopathy (PSE):
-Type A encephalopathy: associated w/ acute liver failure
-Type B encephalopathy: associated with cirrhosis, is of gradual onset & rarely fatal
-Type C encephalopathy: associated w/ portosystemic bypass in the absence of cirrhosis
-Stages of type B encephalopathy:
-Stage 1 (covert): alterations in consciousness & behavior, ranging from inversion of sleep/wake pattern & forgetfulness
-Stage 2 (overt): confusion, bizarre behavior, disorientation
-Stage 3 (overt): lethary, profound disorientation
-Stage 4 (overt): coma
-Obtain urine toxicology
-Start Lactulose (15 mL/day, up to 120 mL/day) and titrate to 2-3 soft bowel movements daily + Rifaximin 550 mg po bid
-After an initial episode of HE, lactulose is recommended for prevention of recurrent episodes of HE with the addition of rifaximin after a second episode

Esophageal/Gastric Varices:
-The patient will need EGD for assessment of varices

Ascites/SBP:
Management of Ascites/SBP:
- Is there absence or presence of ascites? If ascites is present, is it mild, moderate, or severe/tense?
- If pocket for paracentesis is amenable, perform at least diagnostic paracentesis & send off the following studies: fluid culture, cell count, albumin, protein, cytology
- If SBP diagnosed, start Ceftriaxone 2 g IV daily for 5 days and Albumin 1.5 g/kg/day now and Albumin 1.0 g/kg/day in 48 hours (split into 3 doses and administer q8h)
- If LVP performed, please give Albumin afterwards (administer Albumin 8 g/L removed once)
- If no AKI present, can continue w/ diuretics for management of ascites s/p LVP
- Sodium restriction (88 mEq [2000 mg]/day)
- Fluid restriction if Na < 120
- Oral Spironolactone + Oral Furosemide once a day in the mornings in a ratio of 100 mg : 40 mg/day (max 400 mg :160 mg); can be uptitrated everry 3-5 days; if < 50 kg, start w/ 50 mg : 20 mg regimen
- Avoid IV Furosemide, associated w/ volume depletion/azotemia/AKI
- Monitor urine output; goal weight loss < 0.75 kg/day, if higher than this threshold, downtitrate as can lead to volume depletion/azotemia/AKI
- Monitor for & correct electrolyte abnormalities
- Monitor renal function closely
-No clinical or imaging evidence of ascites,
-If ascites present, please obtain paracentesis
-For paracentesis, send off fluid culture, cell count, albumin, protein, cytology

HCC:
-No mass on imaging this admission
-AFP level
-The patient will require outpatient follow-up w/ Hepatology (Dr. James S. Park in the MDP; call 718-283-5900 for appointments) for HCC screening q6-12 months

Renal Function/AKI/Hepatorenal Syndrome:
AKI stages in cirrhosis
- Stage 1: increased creatinine >= 0.3 mg/dL up to 2x baseline
- Stage 2: increased creatinine 2-3x baseline
- Stage 3: increased >3x baseline, creatinine > 4 mg/dL, or RRT
Hepatorenal syndrome diagnostic criteria:
- Cirrhosis w/ ascites
- Elevated serum creatinine meeting AKI criteria
- Lack of improvement in serum creatinine after at least 2 days of hold diuretics & volume expansion w/ albumin of 1 g/kg per day up to 100 g/day
- Absence of nephrotic drugs, shock
- Absence of parenchymal kidney disease (urine protein < 500 mg/dL, urine RBC excretion < 50 cells/HPF, w/ absence of intrinsic kidney disease on ultrasound)
-No evidence of hepatorenal syndrome
-Please obtain urine Na, urine Cr, urine Urea, urine Osm

Coagulopathy:
-INR
-If there are elevations in PT/INR, trial of Vitamin K 10 mg PO x3 days
-Monitor INR

Liver transplant candidacy:
-Documented or undocumented
-Medical insurance
-To be determined after discussion w/ Northwell Transplant Hepatology Team or in the outpatient setting

Preventive Care:
- Hepatitis A vaccination
- Hepatitis B vaccination