How to manage your patient with cirrhosis. HUGO E. VARGAS, M.D, FAASLD, FACG, AGAF, FACP Professor of Medicine MAYO CLINIC, ARIZONA

Transcription

1 How to manage your patient with cirrhosis HUGO E. VARGAS, M.D, FAASLD, FACG, AGAF, FACP Professor of Medicine MAYO CLINIC, ARIZONA

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4 Objectives What we will review: Diagnosis of cirrhosis What do I do with this patient? Brief review of MELD management When do I refer to LT? Special needs in the LTx candidate General Medical Disease Specific Issues Cirrhosis Related Issues

5 Medical Management

6 Cirrhosis in Primary Care Pointers to cirrhosis History EtOH IVDU Endemic disease Family Hx Autoimmune diseases Metabolic d/o

7 Physical Exam clues Neuro findings Asterixis Decreased cognition Abdominal/Genitourinary Prominent abdominal collaterals Hepatosplenomegaly Cruveilhier Baumgarten murmur Ascites Anasarca Testicular atrophy Cutaneous Findings Jaundice Spider angiomata Palmar erythema Terry s nails Miscellaneous Scleral icterus Gynecomastia Dupuytren contracture Muscle wasting Easy bruising Fetor hepatis

8 Laboratory Findings Platelet count < 160,000/L Elevated prothrombin time (INR) Elevated bilirubin Decreased albumin Normal or elevated aminotransferases

9 How do I settle this? Imaging MRI or CT US Combination may be very valuable Liver biopsy When is it needed? AIH, HCC, HFE HHC

10 Medications alerts Agent/class Safe Use w/ caution Contraindicated NSAID X APAP Up to 4g/d Disulfiram X Metformin Beware of LA Statins X PPIs X B blockers X Herbals? unknowns Loop diuretics X Spironolactone X Benzodiazepines X

11 Procedures Always proceed with caution Realize that nobody can clear pts for surgery One can only minimize risks Procedures that are OK: Endoscopy LV Paracentesis Dental surgery Use a risk predictor Go to Google and type Mayo Clinic endstage-liver disease

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14 Medical Management Don t forget the usual suspects: Diabetes Obesity Addiction Hypertension Depression

15 Vaccination Guidelines

16 Disease Year Introduced Why vaccinate? Cases Deaths Cases in 2002 HBV HiB Polio Measles Rubella

17 Vaccination: What do cirrhotic patients need? For the purposes of discussion: Cirrhotic patients awaiting LT Need prevention of hepatitis, pneumonia (influenza) If splenectomy is to be considered asplenic prevention Give vaccines early, before IS

18 Main Practical Point Vaccinate as early as possible: Response rates MUCH better

19 General Practical Points Review vaccination status during first visit Recheck vaccination at referral to LT Review immunization status of household Any live vaccines before transplant Clinic staff and household members should receive influenza vaccine yearly

20 Hepatitis A Virus

21 The Pre-Liver Transplant Pt Hepatitis A There is strong evidence that in face of acute HAV: Chronic HBV can be made worse HBsAg+ older patients Advanced disease HCV infected patients may have increased risk of FHF or death Patients with other causes for ESLD may have worse outcome

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23 HAV vaccine Effectiveness CLD % Cirrhosis 49 98% Decompensated Cirrhosis Liver Transplant % %

24 Hepatitis B Virus

25 HBV vaccine response Liver disease Viral disease Number Dose (mcg) Response % ALD Cirrhosis

26 Vaccination of the pt with cirrhosis HBV CLD Patient Serologies HBsAg+ or HBsAb HBcAb Seronegative No vaccination Infected/immune Role for amnesic response Begin rapid vaccination Repeat if not effective

27 Pneumococcal Vaccine Data from the late 80 s shows increased risk of S. pneumonia disease in cirrhotics Many states mandate and allow non-md order of Pneumococcal vaccine in adults above Recommendations by ACIP stand for vaccination

28 Strategy for LT clinic Review pneumococcal vaccine Ensure that asplenic patients are vaccinated Consider boost for patients not vaccinated for >5yrs

29 Influenza A

30 Influenza A Heightened attention has been paid to Influenza A in CLD Preventable Treatable Reported to cause extra-pulmonary disease in patients with CLD Liver failure Myositis/Myocarditis

31 Influenza A Cirrhotics: 20 patients compared with 8 normal controls 75-85% seroconversion (to each of 3 antigens) Minimal side effects LT recipients: 68% respond to one dose, >80% to two doses

32 Strategy for LT clinic At start of influenza season: Vaccinate staff and families Vaccinate all candidates and recipients Educate staff and patients about disease manifestations Have plan to detect and treat Influenza A

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34 LIVER TRANSPLANT INDICATIONS AND CONTRAINDICATIONS Liver Transplantation Indications Cirrhosis - all causes Intrahepatic malignancy Acute liver failure Metabolic disease Contraindications Extrahepatic malignancy Active infection Active substance abuse Severe co-morbidities

35 Model for End-Stage Liver Disease (MELD) Mathematical survival model created from data on patients undergoing TIPS MELD score estimates risk of 3-month mortality Introduced formally in 2002 Uses 3 objective laboratory values - Serum total bilirubin - Serum creatinine - INR In 2016 Na modifier added

36 CALCULATING MELD SCORE Calculating MELD Scores The formula: MELD=0.957 x Loge(creatinine mg/dl) x Loge(bilirubin mg/dl) x Loge (INR) MELD Na = MELD(i) *(137-Na) [0.033*MELD(i)*(137-Na)] Internet MELD calculator

37 ORGAN ALLOCATION FOR LIVER TRANSPLANT Organ Allocation for Liver Transplant Fulminant hepatic failure has highest priority MELD score determines priority in cirrhosis Amongst patients with same blood type, highest MELD score determines priority Waiting time used only to break ties with identical MELD scores MELD scores are updated at regular intervals

38 MELD Exceptions Hepatocellular carcinoma (HCC) with one lesion between 2-5 cm or two to three lesions <3 cm (Milan criteria) Hepatopulmonary syndrome with PaO 2 <60 mmhg on room air. Portopulmonary hypertension, with mean pulmonary artery pressure (mpap) >25 mmhg at rest but maintained <35 mmhg with treatment. Hepatic artery thrombosis 7 14 days post-liver transplantation. Familial amyloid polyneuropathy, as diagnosed by identification of the transthyretin (TTR) Primary hyperoxaluria with evidence of alanine glyoxylate aminotransferase deficiency (these patients require combined liverkidney transplantation). Cystic fibrosis with FEV1 (forced expiratory volume in 1 second) <40%. Hilar cholangiocarcinoma

39 MELD AND SURVIVAL ON TRANSPLANT WAITING LIST MELD and Survival on Transplant Waiting List % % < Probability of survival (%) % 33.8% Months from listing 12

40 RELATIONSHIP BETWEEN CTP SCORE, MELD SCORE AND 3-MONTH MORTALITY ON THE WAITING LIST Relationship Between CTP Score, MELD Score and 3-Month Mortality - UNOS Waiting List 2001 Score Patients (n) Mortality % MELD < > CTP <

41 MELD SCORE AND RISK OF DEATH AWAITING LIVER TRANSPLANTATION MELD Score and Risk of Death Awaiting Liver Transplantation MELD RR p value p < p < p <0.001

42 EVOLVING CONCEPTS IN ALLOCATION MORTALITY RATES BY MELD TRANSPLANT BENEFIT Evolving Concepts in Allocation: Mortality Rates by MELD Transplant Benefit Waitlist Transplant Mortality rate per 1000 patients HR=3.64 P<0.001 HR=2.35 P<0.001 HR=1.21 P=0.41 HR=0.62 P<0.01 HR=0.38 P< MELD HR=0.22 P<0.001 HR=0.18 P<0.001 HR=0.07 P<0.001 HR=0.04 P< HR=hazard ratio

43 How to manage the MELD Assessment is required at least at 3 mo intervals for least sick Weekly updates for sicker patients When there is acute decompensation need to notify LT center Labwork for updates should be performed on same day

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45 Disease Specific Issues Viral Diseases HCV HBV Cholestatic disorders PSE Alcoholic liver disease Hemochromatosis

46 Disease Specific Issues HCV Patients with low MELD should be considered for DAA tx As MELD rises, HCV+ organs increase the likelihood of LT Aggressive HCC screening (CT q6mo) Vaccinate against HAV/HBV

47 Disease Specific Issues HBV If viral replication ongoing, anti-virals are needed Close monitoring for YMDD mutations, drug toxicity Aggressive HCC screening Discuss prophylaxis after LT with patient

48 Disease Specific Issues Cholestatic disorders Assess bone mineral density Supplement Vit D and Calcium If biphosphonates needed, use I.V. Assess and treat pruritus Consider ursodeoxycholic acid

49 Disease Specific Issues Primary Sclerosing Cholangitis ERCP for tight strictures Aggressive screening for CholangioCA Consider accelerated Colon CA screen for those patients with ulcerative colitis Ursodeoxycholic acid may help with symptoms

50 Disease Specific Issues Alcoholic liver disease Most programs require 6 mo sobriety Consider alcohol contract Enforce screening for alcohol use Patients always at risk for recurrence Smokers may be at higher risk for squamous cell CA.

51 Disease Specific Issues Hemochromatosis Phlebotomy schedule should be continued if safe Monitor for cardiovascular effects Myopathy Conduction problems Aggressive HCC screening

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53 Issues Common to all Cirrhotics

54 NATURAL HISTORY OF CHRONIC LIVER DISEASE SUMMARY Natural History of Chronic Liver Disease Development of cirrhosis Chronic liver disease Compensated cirrhosis Median survival ~ 9 years Development of complications: Variceal hemorrhage Ascites Encephalopathy Jaundice Decompensated cirrhosis Median survival ~ 1.6 years Death Orthotopic liver transplant (OLT)

55 MEDIAN SURVIVAL IN CIRRHOSIS Median Survival in Cirrhosis Compensated Cirrhosis Decompensated Cirrhosis Hepatopulmonary syndrome Spontaneous bacterial peritonitis Hepatorenal syndrome Type 1 Type 2 9 yrs 1.6 yrs 10 mos 9 mos 6 mos 2 wks

56 SURVIVAL TIMES IN CIRRHOSIS Decompensation Shortens Survival 100 Probability of survival All patients with cirrhosis Median survival ~ 9 years Gines et. al., Hepatology 1987;7:122 Decompensated cirrhosis Months Median survival ~ 1.6 years 180

57 NATURAL HISTORY OF CIRRHOSIS Development of Complications in Compensated Cirrhosis Probability of developing event Ascites Jaundice Encephalopathy GI hemorrhage Gines et. al., Hepatology 1987; 7:122 Months

58 VARICES

59 VARICES INCREASE IN DIAMETER PROGRESSIVELY Varices Increase in Diameter Progressively No varices Small varices Large varices Rate of progression stage to stage: 7-8%/year Merli et al. J Hepatol 2003;38:266

60 PREVALENCE OF ESOPHAGEAL VARICES IN CIRRHOSIS Prevalence of Esophageal Varices in Cirrhosis % Overall Child A Child B Child C Pagliaro et al., In: Portal Hypertension: Pathophysiology and Management, 1994: 72

61 MANAGEMENT OF PATIENTS WITHOUT VARICES Treatment of Varices / Variceal Hemorrhage No varices No specific therapy Repeat endoscopy in 2-3 yrs* Varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage * Sooner with cirrhosis decompensation

62 PREVENTION OF FIRST VARICEAL HEMORRHAGE Treatment of Varices / Variceal Hemorrhage No varices Varices No hemorrhage Prevention of first variceal hemorrhage Variceal hemorrhage Recurrent hemorrhage

63 PREVENTION OF FIRST VARICEAL HEMORRHAGE Prevention of First Variceal Hemorrhage Porto-caval shunt Bleeding Death Encephalopathy -blockers Sclerotherapy * * * Significantly heterogeneous Treated better Treated worse Relative risk D Amico et al., Hepatology 1995; 22;332

64 NON-SELECTIVE BETA-BLOCKERS PREVENT FIRST VARICEAL HEMORRHAGE Non-Selective Beta-Blockers Prevent First Variceal Hemorrhage Bleeding rate Control Beta-blocker Absolute rate (~2 year) difference All varices 25% 15% -10% (11 trials) (n=600) (n=590) (-16 to -5) Large varices 30% 14% -16% (8 trials) (n=411) (n=400) (-24 to -8) Small varices 7% 2% -5% (3 trials) (n=100) (n=91) (-11 to 2) D Amico et al., Sem Liv Dis 1999; 19:475

65 THE RISK OF FIRST VARICEAL HEMORRHAGE IS NOT REDUCED BY ADDING ISOSORBIDE MONONITRATE (ISMN) TO BETA-BLOCKERS The Risk of First Bleeding is Not Reduced by Adding Isosorbide Mononitrate (ISMN) to -blockers Free of a first variceal bleeding Survival ns 75 ns % Propranolol + ISMN Propranolol + placebo 25 Propranolol + ISMN Propranolol + placebo 0 1 Years Years 2 García-Pagán et al., Hepatology 2003; 37:1260

66 ISOSORBIDE MONONITRATE (ISMN) MONOTHERAPY IS NOT EFFECTIVE IN PREVENTING FIRST EPISODE OF VARICEAL HEMORRHAGE Isosorbide Mononitrate (ISMN) is Not Useful to Prevent First Variceal Bleed in Patients with Contraindications to -blockers Free of first hemorrhage Placebo ISMN Survival Placebo ISMN % 50 p= ns Years Years García-Pagán et al., Gastroenterology 2001; 121:908

67 VARICEAL BAND LIGATION (VBL) VS. BETA-BLOCKERS (BB) IN THE PREVENTION OF FIRST VARICEAL HEMORRHAGE Variceal Band Ligation (VBL) vs. Beta-Blockers (BB) in the Prevention of First Variceal Bleed Chen 1998 Sarin 1999 De 1999 Jutabha 2000 De la Mora 2000 Lui 2002 Lo 2004 Schepke 2004 Total First hemorrhage Survival Relative risk Favors VBL Favors BB Favors VBL Favors BB Khuroo, et al., Aliment Pharmacol Ther 2005; 21:347

68 MANAGEMENT OF PATIENTS WITH SMALL VARICES WITHOUT PRIOR HEMORRHAGE Treatment of Varices / Variceal Hemorrhage No varices Small varices No hemorrhage Repeat endoscopy in 1-2 years* Beta-blockers? Medium/ large varices No hemorrhage Variceal hemorrhage Recurrent hemorrhage * Sooner with cirrhosis decompensation

69 MANAGEMENT OF PATIENTS WITH MEDIUM/LARGE VARICES WITHOUT PRIOR HEMORRHAGE Treatment of Varices / Variceal Hemorrhage No varices Small varices No hemorrhage Medium/ large varices No hemorrhage Variceal hemorrhage 1) -blockers (propranolol, nadolol) indefinitely 2) Endoscopic variceal ligation in patients intolerant to -blockers Recurrent hemorrhage

70 POLYTETRAFLUOROETHYLENE (e-ptfe)-covered TIPS Polytetrafluoroethylene-covered TIPS stents

71 COVERED STENTS ARE MORE LIKELY TO REMAIN FUNCTIONAL THAN UNCOVERED STENTS Covered Stents Are More Likely to Remain Functional Than Uncovered Stents 100 % free of shunt disfunction Covered p= Uncovered Months Bureau et al. Gastroenterology 2004; 126:469

72 MANAGEMENT OF ASCITES SUMMARY Management of Ascites Chronic liver disease Compensated cirrhosis Decompensated cirrhosis Ascites Diagnosis: Clinical US or CAT scan Treatment: Spironolactone-based No NSAIDs Orthotopic liver transplant (OLT) Death Early diagnosis of SBP: Paracentesis q admission or with symptoms Avoid aminoglycosides

73 NATURAL HISTORY OF ASCITES Natural History of Ascites Portal Hypertension No Ascites HVPG <10 mmhg Mild Vasodilation Uncomplicated Ascites HVPG >10 mmhg Moderate Vasodilation Refractory Ascites HVPG >10 mmhg Severe Vasodilation Hepatorenal Syndrome HVPG >10 mmhg Extreme Vasodilation

74 INITIAL WORKUP OF ASCITES: DIAGNOSIS PARACENTESIS Initial Workup of Ascites Diagnostic Paracentesis Routine PMN count Culture? SBP Protein/Albumin? cirrhotic ascites Glucose, LDH? secondary infection Optional? pancreatic ascites Amylase? malignant ascites Cytology

75 ASCITES FLUID ANALYSIS Ascites Fluid Analysis Routine Optional Albumin Protein PMN cell count Cultures Glucose LDH Amylase Red blood cell count TB smear and culture Cytology Triglycerides

76 ASCITES CAN BE CHARACTERIZED BY SERUM-ASCITES ALBUMIN GRADIENT (SAAG) AND ASCITES PROTEIN Ascites Can Be Characterized by Serum-Ascites Albumin Gradient (SAAG) and Ascites Protein Source of ascites Hepatic sinusoids SAAG > 1.1 Peritoneum SAAG < 1.1 Capillarized sinusoid Ascites protein < 2.5 Normal leaky sinusoid Ascites protein > 2.5 Peritoneal lymph Ascites protein > 2.5 Sinusoidal hypertension -Cirrhosis -Late Budd-Chiari Post-sinusoidal hypertension - Cardiac ascites - Early Budd-Chiari - Veno-occlusive disease Peritoneal pathology - Malignancy - Tuberculosis

77 SERUM-ASCITES ALBUMIN GRADIENT (SAAG) AND ASCITES PROTEIN LEVELS IN THE MOST COMMON CAUSES OF ASCITES Serum-Ascites Albumin Gradient and Ascites Protein Levels in the Most Common Causes of Ascites 4.0 Serum ascites albumin gradient (g/dl) Cirrhotic ascites Cardiac ascites Peritoneal malignancy (75) Ascitic fluid total protein (g/dl) Runyon, Ann Intern Med 1992; 117:215

78 MANAGEMENT OF COMPENSATED CIRRHOSIS SUMMARY Management of Compensated Cirrhosis Chronic liver disease Compensated cirrhosis Diagnosis: Liver biopsy Clinical/LSS Decompensated cirrhosis Death Screen for varices (EGD): Large varices beta-blockers Small varices EGD in 1-2 yrs No varices EGD in 2-3 yrs Orthotopic liver transplant (OLT) Screen for HCC: Imaging and AFP q 6 mos Measures to stop alcohol use Vaccination

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