Table 1

Decompensated cirrhosis consensus summary

ProblemRecommendations
Volume status and end points of resuscitationMAP, TTE, and PAC measurements more reliable than pulse pressure variation or arterial pulse contour
SvO2 and serum lactate can be inaccurate
Fluid resuscitation and vasopressorsBalanced salt solutions recommended over normal saline
Norepinephrine=pressor of choice
Albumin useful in SBP, HRS, and PPCD
Ascites managementPreoperative
Grade 2 ascites: Na+ restriction and diuretics
Grade 3: large volume paracentesis
Consider preoperative TIPS
Postoperative
Consider postoperative TIPS
No recommendation for fluids or drains
Hepatorenal syndromeVolume expansion with albumin, treatment of infections, stopping diuretics
MAP >65 mm Hg with norepinephrine versus terlipressin
GI bleedingCeftriaxone plus vasoactive agent (vasopressin, somatostatin, or octreotide)
Endoscopy within 12 hours
TIPS for recurrent or persistent variceal bleed
CoagulopathyVTE prophylaxis should follow standard of care; can follow viscoelastic testing
Empiric platelet transfusions not indicated for peri-procedural correction of thrombocytopenia
Hepatic encephalopathyAmmonia can exclude but should not be followed as end point
Treatment with non-absorbable disaccharides and rifaximin
NutritionEarly enteral nutrition preferred; protein restriction not beneficial
Hypoglycemia should be aggressively managed
PrognosisClinical scores include MELD, ACLF criteria, CLIF-SOFA
Biomarkers being investigated include cystatin C, copeptin, procalcitonin, and CRP
  • ACLF, Acute-on-Chronic Liver Failure; CLIF-SOFA, Chronic Liver Failure-Sequential Organ Failure Assessment; CRP, C reactive protein; GI, gastrointestinal; HRS, hepatorenal syndrome; MAP, mean arterial pressure; MELD, Model of End-Stage Liver Disease; Na+, sodium; PAC, pulmonary artery catheter; PPCD, postparacentesis circulatory dysfunction; SBP, spontaneous bacterial peritonitis; SvO2, central venous oxygenation level; TIPS, transjugular intrahepatic portosystemic shunt; TTE, transthoracic echocardiography; VTE, venous thromboembolism.