- Management of non- infectious complications in LT listed patients.
| Non-infectious complication | Clinical outcome | Recommendations |
|---|---|---|
| Variceal bleeding | • 20% initial risk of death • Primary and secondary variceal hemorrhage prophylaxis is the standard of care for prevention. • Primary prophylaxis depends on the MELD score | • Carvedilol leads to a greater hemodynamic response than NSBB because of its alpha-adrenergic blockade, but this can worsen fluid accumulation • Hyponatremia should be avoided in high MELD patients. • NSBB will be a better option, but it should be avoided in patients with refractory ascites after SBP development, and those who require variceal band ligation • Secondary prophylaxis with endoscopic banding to obliteration and NSBB/carvedilol, both modalities, if tolerated, are standard of care |
| Renal failure | • Renal dysfunction typically implies a substantially increased risk of mortality, commonly precipitated by a bacterial infection, then hypovolemia. • Other etiologies include HRS and parenchymal nephropathy. | • Identify and treat infection with antibiotic therapy. • Appropriate prophylactic antibiotic therapy should be used in variceal hemorrhage or SBP prophylaxis. • Antibiotic therapy administration should be used when an infection is suspected, and hypovolemia is treated. • Avoid overdosing lactulose, intravenous albumin administration when SBP occurs. • Withdraw diuretics and nephrotoxic drugs. • Vasoconstrictor medications are used to correct peripheral vasodilatation if HRS is suspected. • Midodrine, in combination with octreotide or terlipressin, is suggested, which does not require ICU monitoring |
| Refractory ascites and HH | • Ascites is the most common complication of cirrhosis that leads to hospital admission. • 50% of patients with compensated cirrhosis develop ascites over ten years, and 15% and 44% of patients will die in one and five years, respectively. • HH is a complication seen in approximately 5-16% of patients with cirrhosis, usually with ascites. | • Initial management, both with diuretics and sodium restriction, should be effective in 10-20% of cases. • Predictors of response are mild or moderate ascites/HH, especially with urine Na+ excretion >78 mEq/day. • Spironolactone-based diuretics can be used and then add lop diuretics e.g. furosemide (1:4 ratio to preserve potassium). • In an intractable/recurrent ascites/HH, paracentesis and thoracentesis are often needed to optimize ventilator management and to help treat or prevent pneumonia during hospitalization. • TIPS is a good option in low MELD patients, but contraindicated in high MELD patients |
| Hepatic encephalopathy | • Precipitated by infection, dehydration, gastrointestinal bleeding, worsening hepatic function, TIPS placement, hypokalemia, hyponatremia, and numerous medications | • HE is prevented by avoiding dehydration and electrolyte optimization, specifically potassium repletion to avoid increased renal ammonia-genesis in the presence of hypokalemia, and avoidance of starvation. • Treatment options include: lactulose, rifaximin, sodium benzoate and polyethylene glycol • Replacement of benzodiazepine-derived sleep-aids with diphenhydramine, melatonin, or trazodone can also work. • Patients with TIPS who continue to experience refractory encephalopathy may need their TIPS downsized. |
| Hyponatremia | • Low serum Na levels reflect the intensity of portal hypertension, and is associated with ascites and HRS. Serum Na+ <126 mEq/L at the time of listing is associated with poor outcomes. • The need for intervention in dilutional hyponatremia is dictated by the absolute serum Na level, the rapidity of decrease, and the presence or absence of symptoms. | In asymptomatic patients, fluid restriction and limiting diuretic use are considered first-line interventions. • In symptomatic patients, serum Na should be corrected slowly; a correction of <10 mEq/L to 12 mEq/L in 24 hours and <18 mEq/L in 48 hours is recommended. • Vasopressin receptor antagonists (tolvaptan) remain an effective means of hyponatremia treatment when other therapeutic measures fail, and the risks have been considered |
MELD: Model of End-stage Liver Disease, HRS: hepatorenal syndrome, HH: hereditary hemochromatosis, TIPS: Transjugular Intrahepatic Portosystemic Shunt, NSBB: Non selective Beta Blocker, SBP: Spontaneous Bacterial Peritonitis