Table 5.

- Management of non- infectious complications in LT listed patients.

Non-infectious complication	Clinical outcome	Recommendations
Variceal bleeding	• 20% initial risk of death • Primary and secondary variceal hemorrhage prophylaxis is the standard of care for prevention. • Primary prophylaxis depends on the MELD score	• Carvedilol leads to a greater hemodynamic response than NSBB because of its alpha-adrenergic blockade, but this can worsen fluid accumulation • Hyponatremia should be avoided in high MELD patients. • NSBB will be a better option, but it should be avoided in patients with refractory ascites after SBP development, and those who require variceal band ligation • Secondary prophylaxis with endoscopic banding to obliteration and NSBB/carvedilol, both modalities, if tolerated, are standard of care
Renal failure	• Renal dysfunction typically implies a substantially increased risk of mortality, commonly precipitated by a bacterial infection, then hypovolemia. • Other etiologies include HRS and parenchymal nephropathy.	• Identify and treat infection with antibiotic therapy. • Appropriate prophylactic antibiotic therapy should be used in variceal hemorrhage or SBP prophylaxis. • Antibiotic therapy administration should be used when an infection is suspected, and hypovolemia is treated. • Avoid overdosing lactulose, intravenous albumin administration when SBP occurs. • Withdraw diuretics and nephrotoxic drugs. • Vasoconstrictor medications are used to correct peripheral vasodilatation if HRS is suspected. • Midodrine, in combination with octreotide or terlipressin, is suggested, which does not require ICU monitoring
Refractory ascites and HH	• Ascites is the most common complication of cirrhosis that leads to hospital admission. • 50% of patients with compensated cirrhosis develop ascites over ten years, and 15% and 44% of patients will die in one and five years, respectively. • HH is a complication seen in approximately 5-16% of patients with cirrhosis, usually with ascites.	• Initial management, both with diuretics and sodium restriction, should be effective in 10-20% of cases. • Predictors of response are mild or moderate ascites/HH, especially with urine Na+ excretion >78 mEq/day. • Spironolactone-based diuretics can be used and then add lop diuretics e.g. furosemide (1:4 ratio to preserve potassium). • In an intractable/recurrent ascites/HH, paracentesis and thoracentesis are often needed to optimize ventilator management and to help treat or prevent pneumonia during hospitalization. • TIPS is a good option in low MELD patients, but contraindicated in high MELD patients
Hepatic encephalopathy	• Precipitated by infection, dehydration, gastrointestinal bleeding, worsening hepatic function, TIPS placement, hypokalemia, hyponatremia, and numerous medications	• HE is prevented by avoiding dehydration and electrolyte optimization, specifically potassium repletion to avoid increased renal ammonia-genesis in the presence of hypokalemia, and avoidance of starvation. • Treatment options include: lactulose, rifaximin, sodium benzoate and polyethylene glycol • Replacement of benzodiazepine-derived sleep-aids with diphenhydramine, melatonin, or trazodone can also work. • Patients with TIPS who continue to experience refractory encephalopathy may need their TIPS downsized.
Hyponatremia	• Low serum Na levels reflect the intensity of portal hypertension, and is associated with ascites and HRS. Serum Na+ <126 mEq/L at the time of listing is associated with poor outcomes. • The need for intervention in dilutional hyponatremia is dictated by the absolute serum Na level, the rapidity of decrease, and the presence or absence of symptoms.	In asymptomatic patients, fluid restriction and limiting diuretic use are considered first-line interventions. • In symptomatic patients, serum Na should be corrected slowly; a correction of <10 mEq/L to 12 mEq/L in 24 hours and <18 mEq/L in 48 hours is recommended. • Vasopressin receptor antagonists (tolvaptan) remain an effective means of hyponatremia treatment when other therapeutic measures fail, and the risks have been considered

MELD: Model of End-stage Liver Disease, HRS: hepatorenal syndrome, HH: hereditary hemochromatosis, TIPS: Transjugular Intrahepatic Portosystemic Shunt, NSBB: Non selective Beta Blocker, SBP: Spontaneous Bacterial Peritonitis