Novel approaches in the medical management of compensated cirrhosis

ABSTRACT

Introduction

Classically, clinical practice guidelines and expert recommendations have focused on the management of decompensated cirrhotic patients, so we focused this review on improving care for compensated cirrhotic patients who are followed up in outpatient clinics.

Areas covered

We reviewed the current methods for establishing liver function, the diagnosis and management of advanced chronic liver disease and clinically significant portal hypertension as well as the prevention of its complications, with special attention to covert hepatic encephalopathy, we also paid attention to the extrahepatic complications of cirrhosis and the palliative care. All this from the perspective of evidence-based medicine and trying to empower precision medicine. The literature search was undertaken by PubMed with ‘cirrhosis,’ ‘advanced chronic liver disease,’ ‘liver function,’ ‘portal hypertension,’ ‘covert hepatic encephalopathy,’ ‘minimal hepatic encephalopathy,’ ‘palliative care’ as MeSH terms.

Expert opinion

We must offer compensated cirrhotic patients specific care and measures to prevent the progression of the disease and the appearance of its complications beyond the calculation of liver function and imaging screening for hepatocellular carcinoma that we perform every six months. Entities that have typically received little attention, such as covert hepatic encephalopathy, extrahepatic complications and symptoms of cirrhosis, and palliative care, must come to the spotlight.

KEYWORDS:

• Liver cirrhosis
• advanced chronic liver disease
• compensated cirrhosis
• recompensated cirrhosis
• decompensated cirrhosis
• portal hypertension
• hepatic encephalopathy
• palliative care

Article highlights

• This review focuses on improving care for compensated cirrhotic patients who are followed up in outpatient clinics.

• Attention to the appearance and management of extrahepatic manifestations of cirrhosis, as well as the use of the most effective and safe drugs, are essential to offer quality care to these patients.

• Transient elastography is the most useful method for noninvasive assessment of both compensated advanced chronic liver disease and clinically significant portal hypertension.

• Pharmacologic therapy for portal hypertension decreases the need for endoscopic surveillance, so beta-blockers should be always taken into account and considering the temporal window of opportunity for them.

• Carvedilol could improve the prognosis of cirrhosis by preventing the first decompensation event.

• Minimal hepatic encephalopathy is associated with a higher risk of development of overt hepatic encephalopathy, faster progression of cirrhosis, higher risk of hospitalization and of mortality. The detection and treatment of minimal hepatic encephalopathy can potentially decrease the risk of meeting these outcomes.

• Adopting the principles of palliative care has the potential to decrease symptom burden, improve their quality of life, and save resources. This approach may be chosen even when targeted and curative treatments, including the possibility of liver transplant, are still underway.

Declaration of interest

M. Romero-Gómez has served as a consultant for AbbVie, Alpha-sigma, Allergan, Astra-Zeneca, Axcella, BMS, Boehringer-Ingelheim, Gilead, Intercept, Inventia, Kaleido, MSD, Novo-Nordisk, Pfizer, Prosciento, Rubió, Siemens, Shionogi, Sobi, and Zydus; and has received research grants from Gilead, Intercept, Siemens, and Theratechnologies. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.