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Cirrhosis

Podcasts

Beyond the Mic: Exploring the Journeys of Leaders.

Cholestatic Pruritus Across the Age Spectrum: What Are You Missing?

When considering cholestatic pruritus across the age spectrum, a key point to remember is that while the underlying mechanism is similar, pediatric patients often present with unique challenges in diagnosis and management due to factors like limited communication abilities, potential side effects of medications, and the need for careful dosage adjustments; additionally, older adults might have co-morbidities that complicate treatment and require a more nuanced approach to managing pruritus

Webcasts

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Introducing Recent HRS-AKI Advances into Clinical Care

Nikolaos T. Pyrsopoulos, MD & Marcelo Kugelmas, MD
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ACLF-MELD Calculator

This program is supported by an educational grant from Mallinckrodt Pharmaceuticals.
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AASLD Cirrhosis Guidelines Summary

Dr. David Bernstein
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Publications

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Interactive Expert Perspectives from CLDF on the AASLD Guidelines, HRS

The “Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases” is a comprehensive guidance on the diagnosis, evaluation, and management of the aforementioned complications of cirrhosis. It serves to replace the prior by the American Association for the Study of Liver Diseases (AASLD) guidelines on the same topics published in 2012. The Chronic Liver Disease Foundation (CLDF) is a nonprofit 501(c)(3) educational organization dedicated to raising awareness of liver disease. Members of the CLDF cirrhosis committee, actively involved in the management and treatment of patients with advanced liver disease, cirrhosis, and its complications, have provided their expert perspectives on this updated guidance. The result is this summary, which provides a streamlined version of the practical recommendations set forth in the guidance to facilitate their use in clinical practice.
Cirrhosis directly results in the development of splanchnic vasodilation, portal hypertension, and bacterial translocation. Specifically, splanchnic vasodilation leads to effective arterial underfilling associated with the activation of vasoconstrictor (e.g., renin-angiotensin) and antidiuretic (e.g., arginine vasopressin) factors. Both portal hypertension (because of increased sinusoidal) and bacterial translocation (because of gut permeability) contribute to the pathogenesis of complications associated with ascites, including hyponatremia, acute kidney injury, hepatorenal syndrome, and spontaneous bacterial infections.
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Improving Outcomes in Hepatorenal Syndrome–Acute Kidney Injury With Early Diagnoses and Implementation of Approved Treatment Regimens

Decompensated cirrhosis, defined by the overt manifestations of liver failure and portal hypertension (eg, ascites, hepatic encephalopathy, variceal bleeding), is the inflection point associated with increased morbidity and mortality in chronic liver disease. Acute kidney injury in the setting of cirrhosis (hepatorenal syndrome–acute kidney injury [HRS-AKI]) is a severe and often fatal complication. The goals of treatment of HRS-AKI are to reverse renal failure and prolong survival in these critically ill patients or perhaps to allow the transplant team to complete the pretransplant evaluation and bridge the patient to transplant. Historically, in the United States, standard-of-care treatments for HRS-AKI were chosen by default despite lack of data, off-label use, and suboptimal results. Terlipressin represents the first drug in the United States indicated for the treatment of HRS-AKI. This review provides an up-to-date overview of HRS-AKI, discusses terlipressin and how to incorporate this new treatment into patient care and streamline society guidelines on HRS diagnosis and treatment in a practical way for clinical use, and concludes with a
sample order set that highlights the recommendations discussed throughout the supplement.
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Improving the Management of Hepatorenal Syndrome–Acute Kidney Injury Using an Updated Guidance and a New Treatment Paradigm

Cirrhosis, or advanced scarring of the liver, represents the end stage of chronic liver disease and is associated with high morbidity and mortality. Hepatorenal syndrome–acute kidney injury (HRS-AKI), a condition causing functional and progressive kidney failure, is a complication of cirrhosis that contributes to its high mortality rate. In the United States, the standard-of-care treatments for HRS-AKI have historically been suboptimal. Recently, terlipressin became the first drug approved for HRS-AKI in the United States, and the American Association for the Study of Liver Diseases updated its guidance document on HRS diagnosis and management. Clinical practice guidelines and guidance documents have a variable effect on physician behavior owing to a lack of awareness, familiarity, and education. The implementation of standardized order sets can improve guidance adherence and the quality of care delivered by encouraging datadriven treatment administration, especially for new therapies. This review seeks to facilitate improvements in the management of HRS-AKI by discussing early HRS-AKI interventions, which will streamline diagnosis and treatment in a practical way for clinical use, and how to incorporate new treatments into patient care to improve survival in this subset of patients. Finally, these recommendations are integrated into a sample order set developed by members of the Chronic Liver Disease Foundation and experts in the management of HRS-AKI.