ESLD Flashcards
NAFLD/MASLD Treatment
Overall Goals to Manage Cirrhosis/ESLD
- PROTECT THE LIVER FROM HARM
- Discontinue harmful medications
- Monitor blood pressure
- Avoid alcohol, NSAIDs, herbal medications, raw shellfish
- Maintain vigilance for complications of cirrhosis
- Screen for esophageal varices
- Screen for HCC every 6 months
- Refer for liver transplantation if appropriate
Portal Hypertension
- Normal pressure ~ 6 mmHg
- Clinically significant portal HTN ~ > 10-12 mmHg
CF: ascites, gastroesophageal varices, hepatic encephalopathy, hepatorenal syndrome
Ascites
- Most common complication of cirrhosis
- Clinically evident when > 1500 mL fluid has accumulated
Goals
-Mobilize fluid
-Decrease abdominal discomfort/pain
-Prevent complications
-Wt loss of 0.5-1 L per day
-Urine output should exceed fluid intake by 300-1000 ml/day
Ascites Therapy
Spironolactone 100 mg PLUS Furosemide 40 mg
-can increase every 3-5 days
-maintain 100:40 ratio
-max doses of 400 and 160
-furosemide added to minimize risk of hyperkalemia and enhance diuresis
Ascites, Alternative Diuretic Therapy
- Amiloride 10-40 mg or Eplerenone 25-50 mg
*when gynecomastia is intolerable, less effective - Metolazone 5-20 mg
- Triamterene 50-100 mg
- Torsemide 5-10 mg
- Bumetanide 0.5-2 mg
AEMTTB
Refractory Ascites
when unresponsive to sodium restriction and high-dose diuretic therapy
use Midodrine 7.5 mg po tid (2nd line therapy per AASLD guidelines)
ALSO: paracentesis (remove 1-10 L), albumin 6-8 g/1L IV given when > 5 L
Ascites, Non-Pharmacologic Therapy
-Protein 1-1.5 gm/kg/day
-Sodium < 2 and fluid (if Na < 120) restriction
-Avoid NSAIDs and ACEI/ARB
-DC alcohol
Ascites, Monitoring Parameters
-Body weight, abdominal girth
-Fluid intake
-Urine output
-Urina Na, K
-Hyponatremia, hyperkalemia
-Metabolic alkalosis
-Hypokalemia
-Gynecomastia
Spontaneous Bacterial Peritonitis (SBP)
Infection of the ascitic fluid
-gram-negative enteric bacilli (E.coli, Klebsiella)
Empiric therapy: Cefotaxime or Ceftriaxone IV then streamlined based upon cultures
Prophylaxis: pts with previous SBP episode
-Ciprofloxacin 500 or Rifaximin or Trime-Sulf
Esophageal Varices
Emphasis on PREVENTION of bleeding
-bleeding can be emergency/fatal
Goals
-Volume resuscitation, acute treatment of bleeding, prevention of recurrence
Esophageal Varices, AASLD Guidelines
-Vasoconstrictive Agent
AND
-Endoscopic band/variceal ligation
TIPS indicated for variceal bleeding refractory to pharmacologic and endoscopic therapy
Vasoactive Agents for Treatment of Acute Variceal Bleed
-Octreotide
*AE: diarrhea, abd pain, hyperglycemia, hypoglycemia, constipation
*2-5 days
-Vasopressin (+nitroglycerin) *24 hr
-SMT (not in US)
-Terlpressin *2-5 days
Esophageal Varices, Primary Prophylaxis
Indicated for pts with varices that have not bled and Child’s B or C
-Non selective beta blockers
carvedilol, EVL, nadolol, propranolol
PREVENTION of **recurrent varices* only
*Combination of either propranolol or nadolol + EVL is recommended
Hepatic Encephalopathy (HE)
Metabolic disorder of the CN
*altered mental status, flapping tremor (asterixis), sweet/musty breath
Drug induced CNS depression
-Sedatives, Tranquilizers, Narcotics
Goals
-Provide supportive care
-Identify and remove precipitating factors
-Reduce nitrogenous load from gastrointestinal tract
-Assess need for long-term therapy
Hepatic Encephalopathy Therapy
Acute
-Lactulose 30-45 ml hour, titrate 2-4 soft bowel movements/day
Chronic
-Lactulose 30-45 ml po daily-qid, titrate to 3 soft bowel movements/day
AE: diarrhea, abd cramping, flatulence
*can dilute in juice/water/carb bev
HE Therapy, Rifaximin
-abx with low systemic availability
-wide spectrum activity
-400 mg po tid or 550 po bid
-better tolerability and ~efficacy to lactulose
-often given with lactulose for better efficacy
AE: flatulence, abd pain, angioedema
Hepatorenal Syndrome
- Norepinephrine + albumin
*while patient is in the ICU - Midodrine + octreotide + albumin
*when pt transferred to floor or outpt - Terlipressin – 1st drug for HRS, superior to MOA
NA MOA T
Liver transplantation corrects renal failure
Coagulation Defects
S/Sx: Platelets < 150,000; low albumin, high PT/INR, petechiae, easy bruising
Platelet transfusions; fresh frozen plasma (FFP); avoid IM injections
DRUG INDUCED LIVER INJURY (DILI)
-Isoniazid
-Propylthiouracil
-Phenytoin
-Valproate
-Amanita mushrooms
-Nitrofurantoin
-Herbal
**VAN HIPP*
Acute Hepatic Necrosis
acetaminophen, niacin, methotrexate = toxic injury to liver
MAN toxic to liver
Acute Hepatitis
isoniazid, green tea, herbals (HIG)
ALT > 20 times ULN, fatigue, bilirubin > 2.5 mg/dL
Cholestatic Hepatitis
sulfonylureas, rifampin, penicillins, cephalosporins, methimazole (PS MCR)
Liver enzyme pattern is predominated by increases in alkaline phosphatase (3 times ULN), bilirubin > 2.5 mg/dL
Susceptibility Factors
- Adults > Children
- Women > Men
- Obesity and Malnutrition
- Alcohol use
- Pregnancy
- History of drug reactions
- Preexisting liver disease, coexisting illness
- GENETICS – genetic polymorphisms
-NAT2, UGT1A1, HLA
Treatment of DILI
- Discontinue offending agent
- Administer antidote if available
- Symptomatic and supportive therapy
- Liver Transplantation
- May re-challenge if cholestatic but not hepatocellular
Guidelines for Use of Drugs in Liver Disease
-Conservative use of drugs
-Avoid hepatically eliminated drugs; drugs with active metabolites
-Clinical monitoring
-Avoid sedating medications
-Avoid hepatotoxic agents
-Avoid nephrotoxic agents
-Avoid agents that can precipitate bleeding
-Avoid IM injections
-Utilize Child-Pugh class to guide drug dosing
