Clinical Practice Guidelines презентация

Clinical Practice Guidelines Decompensated cirrhosis

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About these slides

Guideline panel EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Outline EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Methods Grading evidence and recommendations

Grading evidence and recommendations 1. Guyatt GH, et al. BMJ. 2008:336:924–6; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Background Definition and pathophysiology of decompensated cirrhosis

Multi-stage model for the clinical course of cirrhosis D’Amico G, et al. J Hepatol 2018;68:56376; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Multi-stage model for the clinical course of cirrhosis D’Amico G, et al. J Hepatol 2018;68:56376; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Pathophysiology of DC Bernardi M, et al. J. Hepatol 2015;63:1272–84; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management strategies for DC EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Key recommendations

Topics Overall management of DC Suppression of aetiological factor(s) Treatment of key pathogenic factors Management of specific complications of DC Ascites Refractory ascites Hepatic hydrothorax Hyponatremia Gastrointestinal bleeding Bacterial infections Renal impairment Acute-on-chronic liver failure Relative adrenal insufficiency Cardiopulmonary complications

Overall management of DC EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Suppression of aetiological factor(s) EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Treatment of key pathogenic factors EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Ascites EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: evaluation and diagnosis *Ascites recurring on ≥3 occasions within a 12-month period despite dietary sodium restriction and adequate diuretic dosage are considered recurrent EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: evaluation and diagnosis *Grade of evidence II-2, grade of recommendation 1; †Bedside inoculation blood culture bottles with 10 ml fluid each; ‡A total protein concentration <1.5 g/dl is generally considered a risk factor for SBP; §SAAG ≥1.1 g/dl indicates that portal hypertension is involved in ascites formation with an accuracy of about 97% EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: prognosis EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: management EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: recommended diuretics *Spironolactone, canrenone or K-canrenoate; †Body weight reduction <2 kg/week EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: considerations prior to initiating diuretics EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: monitoring of patients receiving diuretics *Serum sodium <125 mmol/L; †10 mg/day, with a weekly increase of 10 mg/day up to 30 mg/day EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: management of Grade 3 ascites *Grade of evidence I, grade of recommendation 1 EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Uncomplicated ascites: contraindicated drugs EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Refractory ascites: definition EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Refractory ascites: diagnostic criteria *Spironolactone 400 mg/day and furosemide 160 mg/day EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Refractory ascites: diagnosis EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Refractory ascites: management *See also section on gastrointestinal bleeding EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Refractory ascites: indications for TIPS *By shunting an intrahepatic portal branch into a hepatic vein EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Hepatic hydrothorax: definition and diagnosis *Grade of evidence III, grade of recommendation 1 EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Hepatic hydrothorax: treatment EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Hepatic hydrothorax: beyond diuretics and thoracentesis EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Hyponatraemia *Beyond fluid restriction, hypertonic saline should be limited to rare patients with life-threatening complications. It can be considered in patients with severe hyponatraemia who are expected to undergo LT within days. Correction of serum sodium concentration after attenuation of symptoms should be slow (≤8 mmol/L per day) to avoid irreversible neurological sequelae (II-3;1). Albumin can be administered but data are very limited (II-3;2). Use of vaptans should be limited to clinical trials (III;1) EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Variceal haemorrhage: pathophysiology and natural history EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Variceal haemorrhage: prevention and treatment *High-risk = small varices with red signs, medium or large varices irrespective of Child–Pugh classification or small varices in Child–Pugh C patients EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Variceal haemorrhage: prophylaxis with NSBBs and EBL *Such as bleeding, sepsis, SBP or AKI EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Variceal haemorrhage: prevention of variceal rebleeding NSBBs and EBL in combination reduces the risk of re-bleeding compared with monotherapy

Variceal haemorrhage: management of acute GI bleeding *History, physical and blood exam, cultures; †Somatostatin/terlipressin; ‡Ceftriaxone (1 g/24 hours) is the first choice in patients with DC, those already on quinolone prophylaxis, and in hospital settings with high prevalence of quinolone-resistant bacterial infections. Oral quinolones (norfloxacin 400 mg BID) should be used in the remaining patients (I;1) Figure adapted from de Franchis R, et al. J Hepatol 2015;63:74352; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Acute variceal haemorrhage: treatment EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of persistent bleeding EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Bacterial infections EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Spontaneous bacterial peritonitis: diagnosis EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Spontaneous bacterial peritonitis: diagnosis *Culture should be performed to guide antibiotic therapy (Grade of evidence II-2, grade of recommendation 1) EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of SBP: empirical antibiotics *Grade of evidence II-2, grade of recommendation 1; †Grade of evidence I, grade of recommendation 1 EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of SBP: empirical antibiotics EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of SBP: use of albumin 1. Sort P, et al. N Engl J Med 1999;341:403–9; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of SBP: primary prophylaxis 1. Wiest R, et al. Gut 2012;61:297–310; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of SBP: secondary prophylaxis 1. Rimola A, et al. J Hepatol 2000;32:142–53; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of other infections *Carbapenem alone or in combination with other antibiotics proved to be superior to third-generation cephalosporins in healthcare-associated infections other than SBP EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Assessing severity of infection 1. Singer M, et al. JAMA 2016;315:801–10; Figure adapted from Piano S, et al. Gut 2017; doi: 10.1136/gutjnl-2017-314324. [Epub ahead of print]; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Other infections: recommended empirical antibiotic treatment Adapted from Jalan R, et al. J Hepatol 2013;60:1310–24; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Other infections: recommended empirical antibiotic treatment Adapted from Jalan R, et al. J Hepatol 2013;60:1310–24; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Renal impairment: definitions *Proteinuria/haeamaturia/ultrasonography abnormalities. †Stage 1A (sCr <1.5mg/dl), Stage 1B (sCr ≥1.5mg/dl) EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Renal impairment: definitions *Proteinuria/haeamaturia/ultrasonography abnormalities. †Stage 1A (sCr <1.5mg/dl), Stage 1B (sCr ≥1.5mg/dl) EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Renal impairment: definitions of kidney disease EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Renal impairment: definitions of kidney disease *International Club of Ascites-recommended adaptation of KDIGO group criteria EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

AKI in patients with cirrhosis: ICA definitions Angeli P, et al. J. Hepatol 2015;62:96874; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

AKI in patients with cirrhosis: ICA definitions *ICA recommended adaptations of KDIGO group criteria Angeli P, et al. J. Hepatol 2015;62:96874; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

ICA management algorithm for AKI in cirrhosis *Initial AKI stage is defined as AKI stage at the time of first fulfilment of the AKI criteria; †Treatment of spontaneous bacterial peritonitis should include albumin infusion according to current guidelines Adapted from Angeli P, et al. J Hepatol 2015;62:968–74; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Differentiating types of AKI 1. Angeli et al. J. Hepatol 2015;62:968–74; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

ICA diagnostic criteria for HRS-AKI *Patients who fulfil these criteria may still have structural damage such as tubular damage Angeli et al. J. Hepatol 2015;62:96874; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of HRS-AKI: treatment *Grade of evidence I, grade of recommendation 1; †Continuous IV infusion allows for dose reduction to reduced adverse effects; ‡ Limited data are available EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of HRS-AKI: screening and monitoring *Continuous IV infusion allows for dose reduction to reduced adverse effects EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of HRS: TIPS and LT EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Prevention of HRS EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Acute-on-chronic liver failure EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

EASL-CLIF prognostic and diagnostic scores for ACLF *Age in years, creatinine in mg/dL, WBC in 106 cells/L, sodium in mmol/L; †Bold text indicates the diagnostic criteria for organ failures; ‡Patients submitted to mechanical ventilation due to HE and not to a respiratory failure were considered as presenting a cerebral failure (cerebral score = 3); §Other patients enrolled in the study with mechanical ventilation were considered as presenting a respiratory failure (respiratory score = 3) 1. Jalan R, et al. J Hepatol 2014;61:1038–47; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Classification and grades of ACLF Moreau R, et al. Gastroenterology 2013;144:1426–37; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Diagnosis of ACLF *Defined as the acute development or worsening of ascites, overt encephalopathy, GI haemorrhage, non-obstructive jaundice and/or bacterial infections; †Note that in a significant proportion of patients, a precipitant factor may not be identified EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of ACLF EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of ACLF EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Relative adrenal insufficiency *Also known as critical illness-related corticosteroid insufficiency (CIRCI) EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Cirrhotic cardiomyopathy EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Cirrhotic cardiomyopathy *Either pharmacologically, or through exercise; †And in the absence of influence of β-blockade EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Cirrhotic cardiomyopathy EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Hepatopulmonary syndrome EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Pathogenesis of HPS EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Diagnostic criteria for HPS EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Diagnosis of HPS *For adults ≥65 years a P[A-a]O2 ≥20 mmHg cut-off should be used EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Diagnosis of HPS EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of HPS EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Portopulmonary hypertension EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Monitoring and medical management of PPHT EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Liver transplantation in PPHT EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Additional recommendations

Portal hypertension gastropathy EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Gastric varices: classification, prevalence and risk EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Management of gastric varices EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Diagnosis of SBP EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Empirical antibiotic treatment of SBP or SBE *In areas with a high prevalence of vancomycin-resistant enterococci Adapted from Jalan R, et al. J Hepatol 2014;60:1310–24; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

AKI management EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

HRS outside AKI criteria *Formerly known as HRS type II EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024

Previous CLIF prognostic and diagnostic scores *Bold text indicates the diagnostic criteria for organ failures; †μg/kg/min 1. Jalan R, et al. J Hepatol 2015;62:831–40; EASL CPG decompensated cirrhosis. J Hepatol 2018;doi: 10.1016/j.jhep.2018.03.024