It is crucial to know the aetiology of cirrhosis as it can help to predict the complications and the line of treatment decisions. This week, Dr. Aju Mathew writes on three important studies of hepatology, focusing on cirrhosis, alerting the risks and helping with the preventive measures that patients should consider.

IV albumin infusion for decompensated cirrhosis

Patients with a history of cirrhosis who have new-onset or worsening ascites, hepatic encephalopathy, or upper gastrointestinal bleeding from varices have decompensated disease. It was thought that giving intravenous albumin to such patients may help reduce inflammation, infection and kidney damage.

Seven hundred and seventy-seven patients with low serum sodium levels (< 3 gram/dl) were randomised to getting daily IV albumin to a goal of 3.5 gram/dl or standard of care for 14 days or until discharge. [1] There was no significant improvement in terms of reducing infection, kidney damage, or death. There was a greater risk for pulmonary oedema in those who got albumin infusion. The majority of patients in this trial had alcoholic cirrhosis.

Based on the results from this trial, should we readdress the common protocol for giving intravenous albumin, a not so inexpensive therapy, across the board for all patients with decompensated cirrhosis? I definitely think the conclusion of the study calls for judicious use.

Infections in cirrhosis

A major aetiology for mortality associated with cirrhosis is infections. In fact, half the infections in patients with cirrhosis are healthcare-related or nosocomial. The most common infection was SBP (spontaneous bacterial peritonitis). The other common causes are UTI and pneumonia.

In India, multidrug-resistant infections are a great threat. In an elegant review article, Bajaj et al discussed the plethora of issues related to infections in patients with cirrhosis. [2] One of the important points of discussion was regarding antibiotic prophylaxis. Daily antibiotics could be considered in high-risk patients – those with acute GI bleeding, those with advanced cirrhosis (Child-Pugh score ≥ 9) at high risk for infection, and those with a history of SBP.

Keep in mind that although antibiotic prophylaxis has been shown to improve survival and reduce rates of infection and re-bleeding, it does come at risk for antibiotic resistance.

Immunotherapy in Hepatocellular carcinoma (HCC)

A cirrhotic liver is fertile soil for HCC. In patients with early-stage disease (refer to Barcelona Clinic Liver Cancer staging system) [3], liver transplant or liver-directed therapy is an option. However, in patients with advanced disease, a game-changing treatment modality has arrived.

In the IMbrave150 trial, patients with unresectable HCC were randomised to receiving an anti-PDL1 monoclonal antibody drug called atezolizumab with an anti-VEGF monoclonal antibody drug called Bevacizumab or sorafenib. At 12-month landmark analysis, 67% of patients on the immunotherapy/VEGF antibody combination were alive when compared to 54% on sorafenib (relative risk reduction for the death of 42%). [4] Although this is a huge breakthrough in this clinical context, the treatment is associated with a significant cost burden. Besides, it is an incurable condition in any case.

The best choice of course is to prevent cirrhosis. More awareness to the general public about the harmful effects of alcohol on their liver needs urgent attention. Safe limits of alcohol consumption need to be highlighted. Prevention is indeed better than cure, or control. Every day in my clinic, I see families being bankrupt with cirrhosis or HCC care. The lasting legacy of alcohol on families is deeply depressing.

A note from Dr. Aju Mathew

I will leave you with one observation from my clinical practice, I am seeing a lot of patients who have never-alcohol users come in with cirrhosis. We may be seeing a slow-growing epidemic of NASH-cirrhosis. In my observation, uncontrolled diabetes is a culprit. What do you think? Have you observed the same phenomenon as well? Email me at cancerkerala@gmail.com.

To read Dr. Aju Mathew's previous articles, click here: Dr Aju Mathew picks 3 clinical updates you should not miss, Dr. Aju Mathew lists 4 new updates in diabetes treatment, Dr. Aju Mathew presents top 3 updates on antibiotics & A hidden side effect of COVID-19 on children: Dr. Aju Mathew

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr Aju Mathew is a medical oncologist, haematologist, internist and epidemiologist practising in Kochi.