Palliative Care for Patients with End-Stage Liver Disease

Abstract

End-stage liver disease (ESLD) is the culmination of progression of chronic liver disease to cirrhosis, decompensation, and chronic liver failure, featuring portal hypertension or hepatocellular failure-related complications. Liver transplantation offers improved long-term survival for these patients but is negatively influenced by donor availability, financial constraints in developing countries, active substance abuse, progression of disease or malignancy on wait-list, sepsis and extrahepatic organ involvement. In this context, palliative care (PC), an interdisciplinary medical practice that aim to prevent and relieve suffering, offers best possible quality of life and is not limited to end-of-life care. It also encompasses achievable goals such as symptom control and aggressive disease-modifying treatments or interventions that beneficially alter the natural course of the disease to offer curative intend. In this narrative review, we discuss the prognostic factors that define disease course in ESLD, various indications and challenges in PC for advanced cirrhosis and management options for major symptom burden in patients with ESLD based on evidence-based best practice.

Keywords: ACLF; ACLF, acute-on-chronic liver failure; CPT, Child–Pugh–Turcotte; ESLD, end-stage liver disease; HE, hepatic encephalopathy; INR, international normalized ratio; LSM, liver stiffness measurement; LT, liver transplantation; MELD, model for end stage liver disease; PC, palliative care; TE, transient elastography; TIPS, transjugular intrahepatic portosystemic shunt; ascites; cirrhosis; end of life care; hepatic encephalopathy; hyponatremia; portal hypertension; sepsis.

Figure 1

Definition, goals, and triggers for palliation in end-stage liver disease. CPT, Child–Pugh–Turcotte score; MELD, model for end-stage liver disease; Na, sodium; ACLF, acute-on-chronic liver failure; ESLD, end-stage liver disease.

Figure 2

Indications for palliation in patients with advanced liver disease. The infographics also depict barrier to palliative care initiation from patient and physician point of view. PC, palliative care.

Figure 3

Brief summary of various treatment options for reducing symptom burden and improving quality of life in patients with advanced liver disease on palliation. BCAA, branched-chain amino acids; NSAIDs, non-steroidal anti-inflammatory drugs; CPT, Child–Pugh–Turcotte score; UDCA, ursodeoxycholic acid; HE, hepatic encephalopathy; FMT, fecal microbiota transplantation; TIPS, transjugular intrahepatic portosystemic shunt; HPS, hepatopulmonary syndrome; POPH, portopulmonary hypertension.