Cirrhosis and MASLD (Santana, 8/6/2025)

 A recording of this presentation is available HERE. 

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Thanks to Dr. Noemi Santana, R3 for kicking off the Senior Resident Grand Rounds series this past week. She gave a sweeping presentation this week on one of my favorite topics, Cirrhosis. See my highlights below.

As was mentioned at our liver transplant GR just a few weeks ago, the liver is responsible for many physiologic activities of the body, including detoxifying the blood, protein synthesis and hormone production. 

Metabolic associated steatotic liver disease (MASLD) is currently defined as hepatic steatosis with at least 1/5 of the following cardiometabolic risk factors:

• obesity
• hypertension
• elevated triglycerides
• decreased HDL
• elevated blood sugars

In the next 20-30 years, MASLD will be the primary indication for liver transplant.

80-90% of people with MASLD are overweight

50-60% have DM2

Many have atherosclerosis, and CKD

There are population differences with regards to additional risk factors including alcohol use (for white), HCV (for African American) and _____________ for Japanese/American Native/Hawaiin, and Latinos.

MASLD is chronically underdiagnosed due to its generally asymptomatic course>> 40% of people with MASLD are diagnosed at their first hospitalization for decompensated cirrhosis. There are currently no standard screening for MASLD, but clinicians should consider risk-based screening for those demonstrating risk factors.

Screening for cirrhosis

• FIB-4 has high NPV (96%) but low PPV (63%) for cirrhosis
• Imaging modalities to assess for cirrhosis
• ultrasound: low sensitivity in early cirrhosis
• Fibro scan (ultrasound w/elastography), MR-E: can be inaccurate in ascites and obesity
• MRI/CT: best for HCC, varices, thrombosis
• Liver biopsy is  still considered gold standard but often reserved for people with unclear etiology

Physical exam in cirrhosis:

• Terry nails (see image)
• gynecomastia
• caput medusae (see image)
• facial telangiectasia (see image)
• palmar erythema
• decreased body hair
• testicular atrophy
• jaundice

Decompensated Cirrhosis

some clinical pearls on common manifestations of decompensate cirrhosis:

• Ascites: be careful with salt restriction as it limits people's diet and may not have enough impact to be indicated, fluid restriction is not indicated unless Na<125
• SBP: defined as >250 PMNs in ascitic fluid
• Varices: >10 mmHg in portal vein is defined as portal hypertension; non-selective beta blockers (nadolol, propranolol) decrease risk of decompensation. Carvedilol is recommended as first line but can decreases MAP
• Hepatic Encephalopathy: consider outpatient use of psychometric HE score, which looks at subtle changes in cognitive capabilities
• HRS/AKI: hepatorenal syndrome defined as SCr not responsive to 2 days of volume explansion; renal injury in cirrhosis portends increased mortality
• Malnutrition and Micronutrient Deficiencies
• pts with cirrhosis need ~0.35 kcal/kg/day (calories) including 1.2-1.5gm/kg/day of protein
• good idea to recommend a late evening protein-rick snack
• screen for deficiencies including Vitamins D/E/B, zinc, and selenium

Emerging therapies for cirrhosis

• Early TIPS: a good discussion here
• Biomarkers (e.g. urine NGAL for AKI in cirrhosis), e.g. a recent paper https://pubmed.ncbi.nlm.nih.gov/33979307/
• Microbiome role in cirrhosis and mitigating disease progression: e.g. https://pmc.ncbi.nlm.nih.gov/articles/PMC7796381/
• Acute on chronic liver disease risk score: CLIF C, used to assess severity of A/CLF