Managing complications of liver cirrhosis and portal hypertension

Abstract

In patients with decompensated cirrhosis, the development of variceal bleeding or hepatorenal syndrome (HRS) is often associated with poor outcome and high mortality rates without liver transplantation. Variceal bleeding occurs at a rate of approximately 5-15% per year in those with established cirrhosis, and treatment comprises of general supportive measures, pharmacological therapy, endoscopic therapy, and rescue therapy for those who have failed pharmacologic and endoscopic therapies. For those with cirrhosis and ascites, the annual in incidence of hepatorenal syndrome (HRS) is an estimated 8%, with a prevalence rate ranging from 13% to 45%. The prognosis is generally poor, with survival usually measured in weeks and months for type 1 and 2 HRS respectively. The pathophysiology of HRS is largely an effect of peripheral vasodilatation, and therefore the primary medical therapy employs the use of vasoconstrictor therapy to improve renal perfusion. The use of albumin increases the effective arterial blood volume, further augmenting the effect of vasoconstrictor therapy. For those that relapse after stopping therapy, re-treatment is often effective, and may be required over a prolonged period as a bridge to liver transplantation. The ultimate treatment for decompensated cirrhosis and HRS is liver transplantation, which significantly improves long-term survival. Therefore, timely referral to a transplant center is essential.