Liver's Last Stand
This hepatic scoring system, which includes INR, bilirubin, and creatinine, is used to prioritize liver transplantation and assess prognosis in advanced cirrhosis.
What is the MELD score?
This IV vasoactive agent is started in acute variceal bleeding to reduce portal pressure and should be initiated before endoscopy when possible.
What is octreotide?
This surrogate marker in ascitic fluid is most critical for diagnosing SBP, even in the absence of positive cultures.
What is an absolute polymorphonuclear (PMN) cell count ≥250 cells/mm³?
Lactulose should be titrated to achieve this number of soft bowel movements per day in patients with HE.
What is 2 to 3 bowel movements per day?
These diuretics are typically first-line therapy for ascites due to cirrhosis.
What is furosemide and spironolactone?
This colloid solution is administered with vasoconstrictors to improve circulatory volume in patients with HRS.
What is albumin?
This routine lab should be monitored frequently in cirrhotic patients on lactulose and diuretics, as both can contribute to neuromuscular dysfunction and arrhythmias.
What is potassium?
Patients with large varices who cannot tolerate beta-blockers should be referred for this endoscopic procedure for primary prophylaxis.
What is endoscopic band (variceal) ligation?
These specific third-generation cephalosporins are most commonly used as first-line empiric therapy for SBP.
What is ceftriaxone or cefotaxime?
In addition to rifaximin, these are two other antibiotics, often added to lactulose in recurrent HE, that targets gut flora that produce ammonia.
What are metronidazole and neomycin?
The maximum recommended daily weight loss for a patient with ascites without edema is this many kilograms.
What is 0.5 kg per day?
This selective vasopressin receptor agonist, recently FDA-approved in the U.S., is considered first-line pharmacologic therapy for HRS.
What is terlipressin?
In compensated cirrhosis, pharmacists should avoid this class of diuretics unless there is clinical evidence of fluid overload due to risk of intravascular depletion.
What are loop diuretics?
In a patient who has experienced recurrent variceal bleeding despite optimal pharmacologic and endoscopic therapy, this interventional procedure is the next step.
What is a TIPS (transjugular intrahepatic porto-systemic shunt) procedure?
Patients with cirrhosis and ascitic protein <1.5 g/dL, plus renal or hepatic impairment, are candidates for secondary prophylaxis with this oral agent.
What is ciprofloxacin or bactrim?
The primary mechanism of lactulose in HE involves lowering this neurotoxic compound by acidifying the gut.
What is ammonia?
This type of paracentesis, used in tense ascites, requires albumin replacement if more than 5 liters of fluid are removed.
What is large-volume paracentesis?
Midodrine is often combined with these two agents as an alternative HRS treatment when terlipressin is unavailable.
What are octreotide and albumin?
This dose-limiting side effect of spironolactone is more common in male patients and may require switching to eplerenone or adjusting therapy.
What is gynecomastia?
Patients on carvedilol for variceal bleeding prophylaxis may experience a greater reduction in portal pressure than with propranolol due to this additional pharmacologic property.
This non-antibiotic therapy, administered IV at 1.5 g/kg on day 1 and 1 g/kg on day 3, improves survival in SBP with renal dysfunction.
What is albumin?
Low levels of this nutrient, involved in ammonia detoxification, may contribute to HE and are sometimes supplemented.
What is zinc?
This sodium restriction recommendation is advised for patients with ascites to improve diuretic response.
What is less than 2 gram per day?
HRS is often precipitated by overuse of these commonly prescribed medications that can reduce effective arterial blood volume and renal perfusion.
What are diuretics?
This clinical sign of portal hypertension may be missed in obese patients but is a key indicator of collateral vessel formation.
What is caput medusae?
This antifibrinolytic agent has no proven benefit in variceal bleeding and is generally not recommended for routine use.
What is tranexamic acid?
These two pathogens are increasing causes of nosocomial SBP and may require broader-spectrum empiric antibiotic coverage.
What are Enterococcus and multidrug-resistant Gram-negative bacilli?
These medications, often used in cirrhotic patients, can worsen HE and should be minimized due to their CNS effects.
What are benzodiazepines?
In patients undergoing repeated large-volume paracentesis, pharmacists should monitor for this hormonal response that may worsen sodium retention long term.
What is activation of the renin-angiotensin-aldosterone system (RAAS)?
This class of drugs should be discontinued in HRS due to their inhibition of compensatory vasoconstriction in the kidneys.
What are ACE Inhibitors or ARBs?