Evidence-based clinical practice guidelines for liver cirrhosis

Key points

• Third edition (2020) of the Japanese liver cirrhosis guideline, now a joint guideline of the Japanese Society of Gastroenterology (JSGE) and the Japan Society of Hepatology (JSH).
• Organized as background questions, clinical questions and future research questions, with reference to the latest EASL and AASLD guidelines.
• Nucleos(t)ide analog therapy for hepatitis B cirrhosis and hepatocellular carcinoma (HCC) surveillance after sustained virological response (SVR) in hepatitis C cirrhosis are strongly recommended.
• For ascites resistant to conventional diuretics, early addition of tolvaptan while renal function is preserved is recommended.
• Rifaximin is strongly recommended as a basic treatment for hepatic encephalopathy.

Overview

This digest presents the JSGE and JSH evidence-based guideline for liver cirrhosis, covering diagnosis, nutrition, antiviral and non-viral therapy and the main complications, through to prognosis prediction and liver transplantation. It updates the 2010 and 2015 editions with new findings and agents from the past 5 years and is based on evidence up to 2019.

Methods

The revision followed the Minds guideline manual. Quality of evidence was graded from A (high) to D (very low), recommendations were rated strong or weak, and consensus was defined as 70% or more agreement. Literature for clinical and future research questions was searched from 1983 to 2018 in English and Japanese databases, and drafts were reviewed by an evaluation committee and opened for public comment.

Diagnosis and nutrition

Fibrosis scores from blood tests and liver stiffness by elastography are useful for diagnosis and are combined in a diagnostic algorithm as noninvasive alternatives to liver biopsy. Energy intake of 25-35 kcal/kg (standard body weight)/day and protein of 1.0-1.5 g/kg/day are advised in the absence of glucose or protein intolerance. Divided meals and a late-evening snack are recommended, and branched-chain amino acids (BCAAs) should be given for protein energy malnutrition.

Viral and non-viral cirrhosis

Nucleos(t)ide analog therapy is recommended in both compensated and decompensated hepatitis B cirrhosis. In hepatitis C, direct-acting antiviral (DAA) therapy is recommended except where the prognosis is poor. Surveillance with imaging and serum tumour markers should continue after SVR, because the annual HCC incidence after DAA-induced SVR is reported at 1.8-2.5%. Long-term alcohol abstinence improves the prognosis of alcoholic cirrhosis, and corticosteroids are proposed for active autoimmune-hepatitis-related cirrhosis.

Complications

Nonselective beta-blockers and isosorbide mononitrate are proposed to prevent variceal bleeding, and vasoactive agents to control it. Ascites is assessed with the serum-ascites albumin gradient, where 1.1 g/dL or more indicates involvement of portal hypertension; salt is restricted to 5-7 g/day, and spironolactone is the first-line diuretic. Spontaneous bacterial peritonitis (SBP) is diagnosed by a positive culture or a neutrophil count of 250/mm3 or more. Noradrenaline with albumin is suggested for hepatorenal syndrome, and non-absorbable disaccharides and rifaximin are the basic treatment for hepatic encephalopathy.

Frequently asked questions

Is HCC surveillance still needed after hepatitis C is cured?

Yes. Surveillance with imaging and serum tumour markers is strongly recommended after SVR, because the annual HCC incidence remains high enough to justify it.

When should tolvaptan be added for ascites?

Early, while renal function is preserved, in patients resistant to spironolactone (25-50 mg/day) with or without furosemide (20-40 mg/day), rather than increasing the spironolactone dose.

What is the prognosis after spontaneous bacterial peritonitis?

The guideline states that the 1-year survival rate from the onset of SBP is approximately 40%.

Source

Yoshiji H, Nagoshi S, Akahane T, Asaoka Y, Ueno Y, Ogawa K, et al. Evidence-based clinical practice guidelines for Liver Cirrhosis 2020. Journal of Gastroenterology 2021;56(7):593-619. DOI: 10.1007/s00535-021-01788-x. Open access. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.