Management of liver cirrhosis between primary care and specialists

Table 6 Key messages for best management of cirrhotic patients

Statement	Evidencelevel
1 A compensated liver cirrhosis is suspected with abnormal liver function tests, low platelets count, and prolonged prothrombin time[63]	III
2 Ultrasonography is a reliable, non-invasive, fast, and cost-effective test working as a first-line tool for diagnosing liver cirrhosis[64]	II-III
3 Child-Pugh and MELD scores assess the prognosis of liver cirrhosis[19,20]	I
4 First-line treatment of patients with cirrhotic ascites includes diuretics and sodium restriction. Anti-aldosterone drugs are given with loop diuretics to increase diuretic response or when renal perfusion is impaired. Dietary salt intake should be restricted to approximately 88 mmol/day (2000 mg/d). Marked salt restriction can expose the risk of hyponatremia[32,37]	I
5 Removal of less than 5 liters of fluid does not appear to have a hemodynamic consequence. For larger paracentesis, albumin (6 to 8 g/L of fluid removed) can be administered. Albumin is indicated in patients with PBS to prevent renal failure, and in patients with hepatorenal syndrome. Albumin can be also used to treat refractory ascites. Its infusion at home is safe and cost-effective[37,65]	II
6 β-blockers (e.g. propranolol or nadolol) are recommended for prophylaxis of variceal bleeding at a dosage titrated to a 25 percent reduction in pulse rate[66]	I
7 Liver transplantation is the only definitive care for patients with major complications (ascites, bleeding, HCC) and/or MELD above 13[1]	I
8 Osteoporosis is an important systemic complication of end-stage liver cirrhosis. Management includes vitamin D and bisphosphonates[53]	II
9 Malnutrition is a negative and independent predictor of survival in patients with liver cirrhosis[67]	II
10 An integrated assistance of patients with liver cirrhosis has a better outcome than the management by generalists/specialists alone[61]	II

LEVEL I : At least one properly conducted RCT, systematic review, or meta-analysis; LEVEL II: Other comparison trials, non-randomized, cohort, case-control, or epidemiologic studies, and preferably more than one study; LEVEL III: Expert opinion or consensus statements (see text for details); MELD: Model for end-stage liver disease.