肝硬化 Liver Cirrhosis 診療指引摘要（2025）
最新建議
- 住院時建議早期進行口服或腸道營養。
- 不建議 protein 限制（包括 hepatic encephalopathy 病人）。
- 建議素食蛋白與 BCAA 攝取。
- 建議晚間點心以減少肌少症與併發症。
- 每日飲用 ≥2 杯 coffee 可降低 fibrosis 進展與 HCC 風險。
常見併發症處理摘要
| 併發症 | 治療摘要 |
|---|---|
| Ascites | 初期使用 spironolactone ± furosemide，Grade 3 考慮 large volume paracentesis + albumin，反覆出現可考慮 TIPS。 |
| SBP | 抽 ascitic fluid 確診後立即給予 IV ceftriaxone；PMN >250/mm³ 啟動治療；若合併 AKI 給予 albumin（1.5 g/kg + 1 g/kg）。 |
| Hepatorenal Syndrome | 使用 albumin + vasoconstrictor（terlipressin 或 norepinephrine）；必要時考慮 RRT 或 liver transplant。 |
| Variceal Hemorrhage | 初期使用 octreotide 或 somatostatin 類藥物合併 endoscopic ligation，嚴重或高風險病人考慮 72hr 內 TIPS。 |
| Hepatic Encephalopathy | 首選 lactulose ± rifaximin；不限制 protein 攝取，建議使用 BCAA。 |
藥物與營養處理原則
- Protein： 建議 1.2–1.5 g/kg/day，不應限制。
- Albumin： SBP + AKI：1.5 g/kg (Day 1)，1 g/kg (Day 3)。
- Diuretics： spironolactone 起始 100 mg/day，搭配 furosemide。
- 避免藥物： NSAIDs, ACEi/ARBs, aminoglycosides。
- Coffee： 每日建議 ≥2 杯。
- Sodium： 建議限制至 <2 g/day，但 frailty 者可放寬。
常用臨床計算器
| 工具名稱 | 用途 |
|---|---|
| Child-Pugh Score | 預估肝硬化死亡風險 |
| MELD-Na | 移植排序依據，預測死亡風險 |
| FIB-4, APRI | 非侵入性肝纖維化指標 |
| MAP Calculator | 灌流壓估算，用於 HRS, AKI 評估 |
| Mumtaz Score | 預測肝硬化再入院風險 |
肝硬化重要臨床研究彙整
| 研究名稱 / 年份 | 研究對象 | 主要比較 | 結論 |
|---|---|---|---|
| LIVERHOPE JAMA, 2025 |
失代償肝硬化病人 | Simvastatin + Rifaximin vs Placebo | 未能顯著降低 ACLF 發生率 |
| 低劑量 vs 標準劑量 Albumin J Clin Exp Hepatol, 2024 |
合併感染的肝硬化病人 | 低劑量 albumin vs 標準劑量 | 住院死亡率相當（noninferior） |
| ATTIRE NEJM, 2021 |
Albumin < 30 g/L 的失代償肝硬化住院病人 | Albumin 補充 vs 標準照護 | 無感染率、腎損傷或死亡率改善 |
| AVB-TIPS Lancet, 2019 |
急性靜脈曲張出血合併重度肝硬化 | Early TIPS vs 標準治療 | Early TIPS 減少死亡或移植需求 |
| ANSWER Lancet, 2018 |
失代償肝硬化病人 | Albumin + 標準治療 vs 單純標準治療 | Albumin 顯著降低 18 個月死亡率 |
| Terlipressin vs Norepinephrine Liver Int, 2017 |
失代償肝硬化 + septic shock | Terlipressin vs Norepinephrine | Terlipressin 提高 MAP > 65 mmHg 的比例 |
| Early TIPS NEJM, 2010 |
靜脈曲張出血後穩定病人 | Early TIPS vs 標準治療 | Early TIPS 提高止血成功與降低再出血 |
| Ceftriaxone Prophylaxis Gastroenterology, 2006 |
嚴重肝硬化 + GI bleeding | Ceftriaxone vs Norfloxacin | Ceftriaxone 降低感染風險 |
| Albumin for SBP NEJM, 1999 |
Cirrhosis + SBP | Cefotaxime + Albumin vs Cefotaxime alone | Albumin 降低腎損傷發生率 |
肝硬化併腹水的藥物處置與指引等級
| 主題 | 建議內容 | 指引來源 | 等級 |
|---|---|---|---|
| 病因處理 | Identify and treat etiological factors (e.g., alcohol, HBV/HCV) | EASL 2018 | B |
| 體重與併發症 | Obesity worsens compensated cirrhosis of all etiologies | Baveno VI 2015 | B |
| 輸液管理 | Consider albumin rather than crystalloids in cirrhosis | ESICM 2024 | C |
| 腹水治療（利尿劑） | Start spironolactone ± furosemide + sodium restriction (2g/day) | AASLD 2021 | E |
| 單用Spironolactone | Initial monotherapy (100–400 mg/day) | BASL/BSG 2021 | B |
| Spironolactone漸增療法 | Start at 100 mg/day, titrate every 72h up to 400 mg | EASL 2018 | A |
| 大容量抽腹水 | Use albumin if >5L removed (8g/L ascites) | BASL/BSG 2021 | A |
| 小於5L腹水抽吸 | Consider albumin if ACLF or high risk of AKI | BASL/BSG 2021 | C |
| Albumin肌肉痙攣用途 | 20-40 g/week for severe muscle cramps | AASLD 2021 | E |
| 腹水藥物治療補充 | Baclofen for cramps; do not use vasoconstrictors | AGA 2023, AASLD 2021 | D–E |
| 腹水難治時考慮TIPS | Early TIPS for recurrent LVP despite therapy | EASL 2025 | B |
| 植入式腹水幫浦 | Low-flow pump in select patients w/ governance | BASL/BSG 2021 | C |
Medical Management Guidelines for Cirrhosis
| Category | Guideline Source | Year | Recommendation | Strength |
|---|---|---|---|---|
| General Principles | ||||
| General Principles | EASL | 2018 | Identify and treat etiological factors in patients with decompensated cirrhosis, particularly alcohol consumption and hepatitis B or C virus infection. | B |
| General Principles | Baveno VI | 2015 | Treat the underlying liver disease to reduce portal hypertension and prevent complications in patients with established cirrhosis. Recognize that obesity worsens the natural history of compensated cirrhosis. | B |
| General Principles | Baveno VI | 2015 | Aim at preventing all complications in the compensated phase of cirrhosis. | B |
| General Principles | Baveno VI | 2015 | Prevent clinically significant portal hypertension in patients without portal hypertension, and prevent decompensation in those with clinically significant portal hypertension. | B |
| Fluid Management | ESICM | 2024 | Consider administering albumin rather than crystalloids in patients with liver cirrhosis. | C |
| Landmark Trial: ATTIRE | Louise China et al., N Engl J Med | 2021 | In patients with decompensated cirrhosis and serum albumin < 30 g/L, albumin was not superior to standard care for infection, kidney dysfunction, or death between days 3-15. | - |
| Management of Ascites | ||||
| Diuretic Therapy | AASLD | 2021 | Initiate diuretics (spironolactone ± furosemide) with moderate sodium restriction (2 g/day) as first-line therapy for grade 2 ascites. | E |
| Diuretic Therapy | BASL/BSG | 2021 | Consider initiating spironolactone monotherapy (100 mg, increased to 400 mg) for first presentation of moderate ascites. | B |
| Diuretic Therapy | EASL | 2018 | Initiate spironolactone (100 mg/day, increase every 72 hours to 400 mg/day) for first episode of grade 2 ascites. | A |
| Intravenous Albumin | ICTMG | 2024 | Consider IV albumin to prevent paracentesis-induced circulatory dysfunction in large-volume paracentesis (> 5 L). | C |
| Intravenous Albumin | AGA | 2023 | Administer IV albumin during large-volume (> 5 L) paracentesis. | E |
| Intravenous Albumin | AASLD | 2021 | Consider human albumin solution (20-40 g/week) for severe muscle cramps. | E |
| Intravenous Albumin | AASLD | 2021 | Insufficient evidence for routine long-term albumin infusion in diuretic-responsive ascites. | I |
| Intravenous Albumin | BASL/BSG | 2021 | Administer albumin (20% or 25%) after > 5 L paracentesis at 8 g/L ascites removed. | A |
| Intravenous Albumin | BASL/BSG | 2021 | Consider albumin (20% or 25%) after < 5 L paracentesis at 8 g/L in high-risk patients. | C |
| Landmark Trial: ANSWER | Paolo Caraceni et al., Lancet | 2018 | Human albumin plus standard treatment was superior to standard treatment alone for death at 18 months in decompensated cirrhosis. | - |
| Other Agents | AGA | 2023 | Do not use vasoconstrictors for uncomplicated ascites after large-volume paracentesis or in SBP. | D |
| Other Agents | AASLD | 2021 | Consider baclofen (10 mg/day, increase to 30 mg/day) for severe muscle cramps. | E |
| Other Agents | EASL | 2018 | Insufficient evidence to support clonidine or midodrine to improve diuretic efficacy. | I |
| Therapeutic Paracentesis | AASLD | 2021 | Perform large-volume paracentesis as first-line therapy for grade 3 ascites, followed by sodium restriction and diuretics. | E |
| Therapeutic Paracentesis | BASL/BSG | 2021 | Consider ultrasound guidance during large-volume paracentesis to reduce adverse events. | C |
| Therapeutic Paracentesis | BASL/BSG | 2021 | Do not routinely measure PT and platelet count before paracentesis or infuse blood products. | D |
| Therapeutic Paracentesis | EASL | 2018 | Perform large-volume paracentesis for grade 3 ascites, followed by plasma volume expansion. | A |
| TIPS | EASL | 2025 | Consider early TIPS to improve outcomes in patients requiring repeated large-volume paracenteses. | B |
| TIPS | BASL/BSG | 2021 | Consider TIPS placement in patients with refractory ascites. | B |
| TIPS | BASL/BSG | 2021 | Be cautious with TIPS in patients with age > 70, bilirubin > 50 µmol/L, platelets < 75×10⁹/L, MELD ≥ 18, hepatic encephalopathy, active infection, or hepatorenal syndrome. | B |
| TIPS | EASL | 2018 | Evaluate patients with refractory or recurrent ascites for TIPS insertion. | A |
| Implantable Peritoneal Pump | BASL/BSG | 2021 | Consider automated low-flow ascites pump in special circumstances with robust governance. | C |
| Implantable Peritoneal Pump | EASL | 2018 | Consider implantable peritoneal pump in experienced centers for refractory ascites not amenable to TIPS, with close monitoring. | B |
| Refractory Ascites | AASLD | 2021 | Advise continued sodium restriction (< 2 g/day) to reduce ascites accumulation. | E |
| Refractory Ascites | BASL/BSG | 2021 | Do not view refractory ascites as a contraindication to nonselective β-blockers. | D |
| Refractory Ascites | EASL | 2018 | Diagnose refractory ascites based on response to diuretics and salt restriction in stable patients. | B |
| Management of Bacterascites | ||||
| Bacterascites | EASL | 2018 | Initiate antibiotics in bacterascites with signs of systemic inflammation or infection. | B |
| Bacterascites | EASL | 2018 | Perform second paracentesis as an alternative to antibiotics; treat if culture remains positive. | B |
| Management of Hepatic Hydrothorax | ||||
| Hepatic Hydrothorax | AASLD | 2021 | Advise sodium restriction, diuretics, and thoracentesis as first-line therapy. | E |
| Hepatic Hydrothorax | BASL/BSG | 2021 | Consider TIPS placement after multidisciplinary discussion. | B |
| Hepatic Hydrothorax | BASL/BSG | 2021 | Consider palliative interventions for patients not undergoing TIPS or transplant. | B |
| Hepatic Hydrothorax | EASL | 2018 | Exclude cardiopulmonary and primary pleural disease before diagnosing hepatic hydrothorax. | B |
| Management of Portal Hypertensive Gastropathy | ||||
| Portal Hypertensive Gastropathy | EASL | 2018 | Initiate nonselective β-blockers, iron supplementation, and/or blood transfusion for chronic hemorrhage. | A |
| Prevention of Gastroesophageal Varices | ||||
| Gastroesophageal Varices | EASL | 2018 | Follow esophageal varices recommendations for primary prevention of type 1 gastroesophageal varices. | B |
| Gastroesophageal Varices | AASLD | 2017 | Insufficient evidence to support nonselective β-blockers for varices prevention. | I |
| Gastroesophageal Varices | AASLD/ACG | 2007 | Do not use nonselective β-blockers to prevent varices development. | D |
| Gastroesophageal Varices | AASLD/ACG | 2007 | Prevent clinically significant portal hypertension and decompensation rather than varices formation. | E |
| Prevention of Variceal Hemorrhage | ||||
| Primary Prevention | ALTA | 2021 | Insufficient evidence for preoperative TIPS to prevent bleeding during nontransplant surgery. | I |
| Primary Prevention | EASL | 2018 | Initiate primary prophylaxis for high-risk varices in decompensated cirrhosis. | A/B |
| Primary Prevention | AASLD | 2017 | Initiate nonselective β-blockers for small varices at high risk of bleeding. | E |
| Primary Prevention | BSG | 2015 | Initiate primary prophylaxis for grade I varices with red signs or grade 2-3 varices. | A |
| Primary Prevention | ASGE | 2014 | Perform endoscopic variceal ligation in patients with large varices intolerant to β-blockers. | B |
| Gastric Varices | EASL | 2018 | Consider nonselective β-blockers for type 2 gastroesophageal or type 1 isolated gastric varices. | C |
| Gastric Varices | AASLD | 2017 | Consider nonselective β-blockers for type 2 gastroesophageal or type 1 isolated gastric varices. | E |
| Gastric Varices | BSG | 2015 | Consider nonselective β-blockers for high-risk large type 2 gastroesophageal varices. | C |
| Secondary Prevention | AASLD | 2017 | Initiate nonselective β-blockers with endoscopic variceal ligation for rebleeding prevention. | E |
| Secondary Prevention | BSG | 2015 | Initiate nonselective β-blockers and variceal band ligation for secondary prophylaxis. | A |
| Secondary Prevention | ASGE | 2014 | Repeat endoscopic variceal ligation until varices are eradicated; repeat every 1-8 weeks. | B/C |
| Management of Variceal Hemorrhage | ||||
| Pharmacotherapy | AGA | 2023 | Administer vasoactive drugs as soon as variceal hemorrhage is suspected, before endoscopy. | E |
| Pharmacotherapy | EASL | 2018 | Initiate volume replacement with colloids/crystalloids; do not use starch. | B/A |
| Pharmacotherapy | AASLD | 2017 | Administer vasoactive drugs as soon as variceal hemorrhage is suspected. | E |
| Pharmacotherapy | BSG | 2015 | Administer vasoconstrictors (terlipressin/somatostatin) until hemostasis or for 5 days. | A |
| Pharmacotherapy | ASGE | 2014 | Administer octreotide for 3-5 days and prophylactic antibiotics for 7 days. | B/A |
| Blood Product Transfusion | EASL | 2018 | Use restrictive transfusion strategy (hemoglobin 7-9 g/dL). | A |
| Blood Product Transfusion | AASLD | 2017 | Transfuse packed RBCs at hemoglobin ~7 g/dL, target 7-9 g/dL. | E |
| Blood Product Transfusion | BSG | 2015 | Administer blood, platelets, and clotting factors for massive bleeding per local protocols. | B |
| Endoscopic Therapy | EASL | 2018 | Perform variceal ligation with vasoactive drugs as first-line therapy. | A |
| Endoscopic Therapy | AASLD | 2017 | Perform endoscopic variceal ligation if variceal bleeding is confirmed/suspected. | E |
| Endoscopic Therapy | BSG | 2015 | Perform variceal band ligation as preferred endoscopic treatment. | A |
| Endoscopic Therapy | ASGE | 2014 | Perform endoscopic variceal ligation or sclerotherapy if ligation is difficult. | B/C |
| TIPS | ALTA | 2021 | Perform preemptive TIPS in high-risk patients within 72 hours. | B |
| TIPS | EASL | 2018 | Consider early preemptive TIPS in high-risk patients or as rescue therapy. | B/A |
| TIPS | AASLD | 2017 | Perform early preemptive TIPS within 72 hours in high-risk patients. | E |
| TIPS | BSG | 2015 | Consider early covered TIPS in selected patients. | C |
| TIPS | ASGE | 2014 | Perform TIPS if endoscopic/pharmacological therapies fail. | B |
| Balloon-Occluded Retrograde Transvenous Obliteration | AASLD | 2017 | Perform TIPS or balloon-occluded retrograde transvenous obliteration for type 2 gastroesophageal or type 1 gastric variceal rebleeding prevention. | E |
| Balloon Tamponade | EASL | 2018 | Perform balloon tamponade for uncontrolled bleeding as a temporary bridge; consider esophageal stents. | B |
| Balloon Tamponade | ASGE | 2014 | Perform balloon tamponade if initial endoscopic therapy fails, until definitive therapy. | C |
| Sengstaken-Blakemore Tube | BSG | 2015 | Insert Sengstaken-Blakemore tube for difficult-to-control bleeding until further treatment. | B |
| Gastric Varices | ALTA | 2021 | Manage bleeding gastric-fundal varices based on center expertise; consider variceal obliteration/embolization ± TIPS. | B |
| Gastric Varices | EASL | 2018 | Treat gastric variceal hemorrhage medically; use cyanoacrylate for cardiofundal varices. | B |
| Gastric Varices | BSG | 2015 | Treat type 1 gastroesophageal varices as esophageal varices. | B |
| Gastric Varices | ASGE | 2014 | Perform gastric variceal obturation with cyanoacrylate or endoscopic variceal ligation. | C/B |
| Surveillance | ALTA | 2021 | Obtain Doppler ultrasound 3 months post-TIPS and every 6 months; consider TIPS venogram for stenosis. | B/C |
| Surveillance | AASLD | 2017 | Avoid routine hepatic venous pressure gradient monitoring. | D |
| Surveillance | ASGE | 2014 | Obtain endoscopic surveillance every 3-6 months post-treatment; treat recurrent varices. | B |
| Management of Coagulopathy | ||||
| Coagulopathy | EASL | 2022 | Do not correct abnormal INR, aPTT, platelet count, or fibrinogen to prevent spontaneous bleeding. | D |
| Coagulopathy | ACG | 2020 | Do not administer FFP to improve thrombin generation at conventional doses. | D |
| Management of Portal Vein Thrombosis | ||||
| Portal Vein Thrombosis | AGA | 2025 | Initiate urgent anticoagulation for portal vein thrombosis with intestinal ischemia. | E |
| Portal Vein Thrombosis | AASLD | 2021 | Insufficient evidence for treatment indications without ischemic symptoms; consider case-by-case. | I |
| Portal Vein Thrombosis | ACG | 2020 | Initiate anticoagulation for acute complete main portal vein thrombosis or mesenteric vein thrombosis. | B |
| Portal Vein Thrombosis | EASL | 2016 | Implement prophylaxis for gastrointestinal bleeding before anticoagulation. | A |
| Prevention of DVT | ||||
| DVT Prevention | EASL | 2022 | Consider LMWH or DOACs (Child-Pugh A/B) for thromboprophylaxis; avoid DOACs in Child-Pugh C. | C |
| DVT Prevention | ISTH | 2022 | Do not view thrombocytopenia/PT/INR prolongation as contraindications to thromboprophylaxis; use LMWH/fondaparinux. | D/E |
| Management of DVT | ||||
| DVT Management | EASL | 2022 | Be cautious with VKAs; use LMWH/VKAs for Child-Pugh A, LMWH for B/C, UFH for renal failure. | B |
| DVT Management | EASL | 2022 | No major concerns for DOACs in Child-Pugh A; be cautious in B or CrCl < 30 mL/min; avoid in C. | B |
| Prevention of SBP | ||||
| Primary Prevention | AASLD | 2021 | Administer IV ceftriaxone (1 g/24h, max 7 days) for SBP prophylaxis in GI hemorrhage; consider in high-risk patients. | E |
| Primary Prevention | BASL/BSG | 2021 | Administer prophylactic antibiotics for GI bleeding with ascites; consider in high-risk patients. | A/B |
| Primary Prevention | AASLD/ACG | 2007 | Administer short-term (max 7 days) antibiotic prophylaxis for GI hemorrhage. | A |
| Secondary Prevention | AASLD | 2021 | Initiate long-term norfloxacin; consider ciprofloxacin if unavailable. | E |
| Secondary Prevention | BASL/BSG | 2021 | Consider norfloxacin, ciprofloxacin, or co-trimoxazole for secondary prophylaxis. | C |
| Secondary Prevention | EASL | 2018 | Initiate norfloxacin (400 mg/day); insufficient evidence for rifaximin. | A/I |
| Management of SBP | ||||
| Antibiotic Therapy | AASLD | 2021 | Initiate empiric IV antibiotics for ascites/pleural fluid PMN > 250/mm³. | E |
| Antibiotic Therapy | BASL/BSG | 2021 | Initiate immediate empirical antibiotics based on context and resistance patterns. | B |
| Antibiotic Therapy | BASL/BSG | 2021 | Consider second paracentesis at 48 hours to check antibiotic efficacy. | C |
| Antibiotic Therapy | EASL | 2018 | Initiate empiric IV antibiotics immediately after SBP diagnosis. | B |
| Intravenous Albumin | ICTMG | 2024 | Consider IV albumin to reduce mortality in SBP. | C |
| Intravenous Albumin | AGA | 2023 | Administer IV albumin during large-volume (> 5 L) paracentesis. | E |
| Intravenous Albumin | AASLD | 2021 | Administer IV albumin (1.5 g/kg day 1, 1 g/kg day 3) in SBP, especially with AKI/jaundice. | E |
| Intravenous Albumin | BASL/BSG | 2021 | Administer albumin (1.5 g/kg within 6h, 1 g/kg day 3) in SBP with rising creatinine. | B |
| Intravenous Albumin | EASL | 2018 | Administer albumin (1.5 g/kg at diagnosis, 1 g/kg day 3) in SBP. | A |
| Vasoactive Agents | AGA | 2023 | Do not use vasoconstrictors in SBP. | D |
| Medications to Avoid | AASLD | 2021 | Avoid aminoglycosides; temporarily discontinue β-blockers in SBP with hypotension/AKI. | D/E |
| Medications to Avoid | EASL | 2018 | Discontinue β-blockers in SBP; attempt reinitiation after recovery; restrict PPIs. | B |
| Management of Other Infections | ||||
| Evaluation | EASL | 2018 | Assess and monitor hospitalized patients for infections to enable early diagnosis. | B |
| Antibiotic Therapy | EASL | 2018 | Initiate empirical antibiotic therapy promptly if infection is suspected. | B |
| Intravenous Albumin | ICTMG | 2024 | Avoid IV albumin in extraperitoneal infections to reduce mortality or kidney failure. | D |
| Intravenous Albumin | EASL | 2018 | Do not use albumin routinely in infections other than SBP. | D |
| Landmark Trial: Albumin in Infection | Jayadeep V Devisetty et al., J Clin Exp Hepatol | 2024 | Low-dose albumin was noninferior to standard-dose for in-hospital mortality in cirrhosis with infections. | - |
| Management of Hepatopulmonary Syndrome | ||||
| Hepatopulmonary Syndrome | SCCM | 2020 | Provide supportive care with supplemental oxygen pending liver transplantation. | E |
| Hepatopulmonary Syndrome | EASL | 2018 | Initiate long-term oxygen therapy for severe hypoxemia; insufficient evidence for effectiveness. | B |
| Hepatopulmonary Syndrome | EASL | 2018 | Insufficient evidence for medical therapy or TIPS placement. | I |
| Hepatopulmonary Syndrome | ILTS | 2016 | No medical therapies definitively established for hepatopulmonary syndrome. | B |
| Management of Portopulmonary Hypertension | ||||
| Portopulmonary Hypertension | SCCM | 2020 | Consider pulmonary arterial hypertension agents for mean pulmonary artery pressure > 35 mmHg. | C |
| Portopulmonary Hypertension | EASL | 2018 | Offer therapies for primary pulmonary arterial hypertension; be cautious with endothelin antagonists. | B |
| Portopulmonary Hypertension | ILTS | 2016 | Offer pulmonary artery hypertension agents to improve hemodynamics and exercise capacity. | B |
| Management of Hepatorenal Syndrome | ||||
| Pharmacotherapy | AGA | 2023 | Administer IV albumin as first-line volume expander in AKI with ascites. | E |
| Pharmacotherapy | ACG | 2022 | Consider terlipressin or norepinephrine for renal function in hepatorenal syndrome-AKI. | C |
| Landmark Trial: CONFIRM | Florence Wong et al., N Engl J Med | 2021 | Terlipressin was superior to placebo for verified reversal of type 1 hepatorenal syndrome. | - |
| Pharmacotherapy | AASLD | 2021 | Manage with multidisciplinary team including hepatology, nephrology, critical care, and transplant surgery. | E |
| Pharmacotherapy | SCCM | 2020 | Administer vasopressors in critically ill patients with acute-on-chronic liver failure and hepatorenal syndrome. | B |
| Pharmacotherapy | EASL | 2018 | Administer vasoconstrictors and albumin in AKI-hepatorenal syndrome stage > 1A. | B |
| Pharmacotherapy | EASL | 2018 | Discontinue diuretics, β-blockers, vasodilators, NSAIDs, and nephrotoxic drugs. | B |
| Pharmacotherapy | AASLD | 2017 | Decrease or hold β-blockers in refractory ascites and hepatorenal syndrome; reintroduce if improved. | E |
| RRT | AASLD | 2021 | Initiate RRT in transplant candidates with worsening renal function or volume overload. | E |
| RRT | AASLD | 2021 | Initiate RRT with clear endpoint in non-transplant candidates. | E |
| RRT | EASL | 2018 | Decide on RRT based on individual severity of illness. | B |
| Therapeutic Paracentesis | EASL | 2018 | Administer albumin with paracentesis in AKI and tense ascites, even for low-volume removal. | B |
| TIPS | EASL | 2018 | Insufficient evidence for TIPS in hepatorenal syndrome-AKI; consider in selected patients outside AKI criteria. | I/C |
| Management of Hepatic Encephalopathy | ||||
| Hepatic Encephalopathy | EASL | 2018 | Avoid initiating diuretic therapy in persistent overt hepatic encephalopathy. | D |
| Hepatic Encephalopathy | AASLD/EASL | 2014 | Treat hepatic encephalopathy as a continuum from unimpaired cognition to coma. | A |
| Management of Hyponatremia | ||||
| Hyponatremia | AASLD | 2021 | Monitor and advise water restriction in mild hyponatremia (126-135 mEq/L) without symptoms. | E |
| Hyponatremia | EASL | 2018 | Recognize hyponatremia (< 130 mmol/L) as ominous; evaluate for liver transplantation. | B |
| Management of Anemia | ||||
| Anemia | EASL | 2022 | Optimize hemoglobin by treating iron, folate, B6, and B12 deficiencies, especially pre-procedure. | B |
| Anemia | EASL | 2022 | Do not administer prophylactic RBC transfusion to decrease procedure-related bleeding. | D |
| Management of Relative Adrenal Insufficiency | ||||
| Relative Adrenal Insufficiency | EASL | 2018 | Do not use hydrocortisone for relative adrenal insufficiency in cirrhosis. | D |
| Prevention of Sarcopenia and Frailty | ||||
| Sarcopenia and Frailty | AASLD | 2021 | Provide education and support to reduce risk of malnutrition, frailty, and sarcopenia. | E |
| Management of Sarcopenia and Frailty | ||||
| Sarcopenia and Frailty | AASLD | 2021 | Treat inflammatory conditions (HCV, insulin resistance, obesity, alcohol use) to manage malnutrition, frailty, and sarcopenia. | E |
| Medications to Avoid | ||||
| Medications to Avoid | AASLD | 2021 | Avoid NSAIDs, ACEis, ARBs, and aminoglycosides in cirrhosis with ascites. | D |
| Medications to Avoid | EASL | 2018 | Do not use NSAIDs, ACEis, ARBs, or α-1 receptor blockers in ascites due to risk of renal impairment. | D |
| Nonpharmacologic Interventions | ||||
| Physical Activity | AASLD | 2021 | Offer physical activity-based interventions with frailty/sarcopenia assessment, aerobic/resistance exercises, and tailored recommendations. | E |
| Physical Activity | EASL | 2018 | Insufficient evidence to support prolonged bed rest for ascites. | I |
| Weight Loss | AASLD | 2021 | Do not perform endoscopic procedures without clear indications (e.g., polypectomy, ERCP, and liver biopsy). | D |
| Surgical Interventions | ||||
| Liver Transplantation | AASLD | 2021 | Consider referring patients with grade 2 or 3 ascites for liver transplantation evaluation. | E |
| Liver Transplantation | EASL | 2018 | Evaluate patients with refractory ascites or hydrothorax for liver transplantation. | B |
| Liver Transplantation | ILTS | 2016 | Consider liver transplantation in severe hypoxemia due to hepatopulmonary syndrome (PaO2 < 60 mmHg). | B |
| Liver Transplantation | AASLD | 2014 | Evaluate for liver transplantation after index complication or MELD ≥ 15. | B |
| Liver Transplantation | AASLD/EASL | 2014 | Offer liver transplantation in recurrent intractable overt hepatic encephalopathy with liver failure. | A |
| Elective Hernia Repair | AASLD | 2021 | Perform elective hernia repair with multidisciplinary approach after ascites control and optimization. | E |
| Elective Hernia Repair | AASLD | 2021 | Consider TIPS before elective hernia repair or after emergent surgery in uncontrolled ascites. | E |
| Elective Hernia Repair | BASL/BSG | 2021 | Discuss suitability and timing of umbilical hernia repair with multidisciplinary team. | B |
| Specific Circumstances | ||||
| Pediatric Patients | AASLD | 2025 | Consider blood-based noninvasive tests (APRI, FIB-4) for advanced fibrosis detection. | - |
| Pediatric Patients | AASLD | 2021 | Obtain comprehensive evaluation for ascites diagnosis in pediatric patients. | E |
| Patients with Obesity | ESPEN/UEG | 2023 | Obtain nutritional screening in cirrhosis with overweight/obesity using validated tools. | B |
| Acute-on-Chronic Liver Failure | EASL | 2018 | Diagnose acute-on-chronic liver failure in cirrhosis with acute decompensation and organ failures. | B |
| Acute-on-Chronic Liver Failure | EASL | 2018 | No specific therapy except antiviral therapy for HBV-related acute-on-chronic liver failure. | B |
| Follow-up and Surveillance | ||||
| Surveillance for Malignancy | BSG | 2024 | Consider 6-monthly ultrasound and α-fetoprotein for HCC surveillance. | B |
| Surveillance for Malignancy | EASL/ILCA | 2023 | Consider 6-monthly ultrasound for intrahepatic cholangiocarcinoma detection. | C |
| Surveillance for Malignancy | EASL | 2022 | Consider 6-monthly screening for hepatobiliary malignancy in PSC with cirrhosis. | C |
| Surveillance for Malignancy | AASLD | 2018 | Obtain HCC surveillance by ultrasound ± α-fetoprotein every 6 months; avoid in Child’s C unless on transplant list. | B/D |
| Surveillance for Malignancy | ESMO | 2018 | Obtain HCC surveillance in all cirrhosis patients with ultrasound ± α-fetoprotein every 6 months. | B/A |
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