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Introduction As people's understanding of the pathophysiology of liver cirrhosis and its complications continues to deepen, some new treatment methods and management strategies have emerged in recent years
.
However, some aspects of the management of liver cirrhosis still have a less clear evidence base and/or there are still differences of opinion among practitioners
.
Recently, J Hepatol (impact factor 20.
582) published a review in which scholars from Italy, the United Kingdom, France and other places provided guidance and recommendations on controversial areas in the management of complications of liver cirrhosis based on current evidence, including liver cirrhosis complicated by chronic diseases.
Recommendations for the management of kidney disease (CKD), type 2 diabetes (T2DM), and hepatic encephalopathy (HE)
.
How to diagnose and treat decompensated liver cirrhosis with CKD? In view of the high prevalence of CKD in patients with liver cirrhosis, especially in patients with metabolic syndrome, patients with liver cirrhosis should be screened for CKD
.
For candidates for liver transplantation (LT), the glomerular filtration rate (GFR) should be measured by the clearance rate of exogenous markers, because the current estimation of GFR in decompensated cirrhosis is poor
.
Candidates for LT may be candidates for combined liver and kidney transplantation
.
So far, there is no specific treatment for CKD complicated by decompensated cirrhosis, because renal protection treatment strategies are disabled in decompensated cirrhosis
.
When end-stage renal disease occurs, renal replacement therapy (RRT) may be used as a bridge for transplantation
.
Should patients with decompensated liver cirrhosis be screened for T2DM? How to treat T2DM? Patients with decompensated cirrhosis should be screened for diabetes because of the high prevalence of diabetes in this population
.
Glycated hemoglobin (HbA1c) should not be used to diagnose or evaluate blood sugar control in the past 3 months
.
The main goal of T2DM treatment is to strictly control blood sugar
.
Self-monitoring and/or continuous monitoring of blood glucose can help optimize blood glucose control, but in decompensated liver cirrhosis, monitoring HbA1c is not accurate because its levels may be reduced by several mechanisms
.
Therefore, self-monitoring of blood glucose is the only way to assess blood glucose control
.
Insulin therapy is the only evidence-based option for the treatment of T2DM
.
Due to the high changes in blood glucose levels and the risk of hypoglycemia, insulin therapy should be started in the hospital.
The psychological changes that may result from treatment may be confused with HE, which complicates management
.
The optimal fasting blood glucose level should not exceed 10 mmol/L to avoid complications of hyperglycemia
.
How to manage decompensated liver cirrhosis with HE? Mild HE is very common and may affect the patient's quality of life and self-care ability.
As time goes by, mild HE is more related to the possibility of overt HE
.
Screening tools for mild HE are easily available and do not require specialized equipment, which may facilitate follow-up and disease monitoring
.
The treatment of mild HE should be considered as a "prevention" to prevent the occurrence of more serious overt HE
.
Treatment challenges may help diagnose the disease
.
In the absence of experience in diagnosing mild HE, the response to a course of ammonia-lowering therapy can help diagnose the disease
.
What are the limitations of non-selective beta blockers (NSBB) in the treatment of decompensated liver cirrhosis? NSBB is not absolutely contraindicated in decompensated liver cirrhosis
.
However, high doses of NSBB should be avoided
.
For patients with progressive hypotension (systolic blood pressure <90 mmHg), during acute diseases such as sepsis, spontaneous bacterial peritonitis (SBP) or acute kidney injury (AKI), NSBB should be temporarily stopped or titrated to avoid further damage to the cardiovascular system Function
.
Low-dose carvedilol should be considered as a treatment option for decompensated liver cirrhosis
.
The guidelines do not recommend the use of carvedilol in patients with refractory ascites because of concerns about its potential antihypertensive effect
.
Recent studies have shown that carvedilol is safe at low doses (6.
25-12.
5 mg), provided that the patient maintains a systolic blood pressure ≥90 mmHg
.
In addition, carvedilol has the effect of reducing inflammation and mitochondrial dysfunction
.
Importantly, carvedilol has been shown to improve the survival rate of patients with ascites
.
Literature index: Garcia-Pagan JC, Francoz C, Montagnese S, et al.
Management of the major complications of cirrhosis: Beyond guidelines[J].
J Hepatol.
2021 Jul;75 Suppl 1:S135-S146.
.
However, some aspects of the management of liver cirrhosis still have a less clear evidence base and/or there are still differences of opinion among practitioners
.
Recently, J Hepatol (impact factor 20.
582) published a review in which scholars from Italy, the United Kingdom, France and other places provided guidance and recommendations on controversial areas in the management of complications of liver cirrhosis based on current evidence, including liver cirrhosis complicated by chronic diseases.
Recommendations for the management of kidney disease (CKD), type 2 diabetes (T2DM), and hepatic encephalopathy (HE)
.
How to diagnose and treat decompensated liver cirrhosis with CKD? In view of the high prevalence of CKD in patients with liver cirrhosis, especially in patients with metabolic syndrome, patients with liver cirrhosis should be screened for CKD
.
For candidates for liver transplantation (LT), the glomerular filtration rate (GFR) should be measured by the clearance rate of exogenous markers, because the current estimation of GFR in decompensated cirrhosis is poor
.
Candidates for LT may be candidates for combined liver and kidney transplantation
.
So far, there is no specific treatment for CKD complicated by decompensated cirrhosis, because renal protection treatment strategies are disabled in decompensated cirrhosis
.
When end-stage renal disease occurs, renal replacement therapy (RRT) may be used as a bridge for transplantation
.
Should patients with decompensated liver cirrhosis be screened for T2DM? How to treat T2DM? Patients with decompensated cirrhosis should be screened for diabetes because of the high prevalence of diabetes in this population
.
Glycated hemoglobin (HbA1c) should not be used to diagnose or evaluate blood sugar control in the past 3 months
.
The main goal of T2DM treatment is to strictly control blood sugar
.
Self-monitoring and/or continuous monitoring of blood glucose can help optimize blood glucose control, but in decompensated liver cirrhosis, monitoring HbA1c is not accurate because its levels may be reduced by several mechanisms
.
Therefore, self-monitoring of blood glucose is the only way to assess blood glucose control
.
Insulin therapy is the only evidence-based option for the treatment of T2DM
.
Due to the high changes in blood glucose levels and the risk of hypoglycemia, insulin therapy should be started in the hospital.
The psychological changes that may result from treatment may be confused with HE, which complicates management
.
The optimal fasting blood glucose level should not exceed 10 mmol/L to avoid complications of hyperglycemia
.
How to manage decompensated liver cirrhosis with HE? Mild HE is very common and may affect the patient's quality of life and self-care ability.
As time goes by, mild HE is more related to the possibility of overt HE
.
Screening tools for mild HE are easily available and do not require specialized equipment, which may facilitate follow-up and disease monitoring
.
The treatment of mild HE should be considered as a "prevention" to prevent the occurrence of more serious overt HE
.
Treatment challenges may help diagnose the disease
.
In the absence of experience in diagnosing mild HE, the response to a course of ammonia-lowering therapy can help diagnose the disease
.
What are the limitations of non-selective beta blockers (NSBB) in the treatment of decompensated liver cirrhosis? NSBB is not absolutely contraindicated in decompensated liver cirrhosis
.
However, high doses of NSBB should be avoided
.
For patients with progressive hypotension (systolic blood pressure <90 mmHg), during acute diseases such as sepsis, spontaneous bacterial peritonitis (SBP) or acute kidney injury (AKI), NSBB should be temporarily stopped or titrated to avoid further damage to the cardiovascular system Function
.
Low-dose carvedilol should be considered as a treatment option for decompensated liver cirrhosis
.
The guidelines do not recommend the use of carvedilol in patients with refractory ascites because of concerns about its potential antihypertensive effect
.
Recent studies have shown that carvedilol is safe at low doses (6.
25-12.
5 mg), provided that the patient maintains a systolic blood pressure ≥90 mmHg
.
In addition, carvedilol has the effect of reducing inflammation and mitochondrial dysfunction
.
Importantly, carvedilol has been shown to improve the survival rate of patients with ascites
.
Literature index: Garcia-Pagan JC, Francoz C, Montagnese S, et al.
Management of the major complications of cirrhosis: Beyond guidelines[J].
J Hepatol.
2021 Jul;75 Suppl 1:S135-S146.
