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Cirrhosis is pathologic scarring of liver tissue that leads to impaired liver function. It can result from any etiology of chronic liver inflammation and causes significant disease burden. Cirrhosis potentially is reversible through management of the cause, such as nonalcoholic fatty liver disease, viral hepatitis, or alcohol use. As liver disease progresses, compensated (ie, asymptomatic) cirrhosis may decompensate, causing ascites, hepatic encephalopathy, or variceal bleeding. Cirrhosis typically is diagnosed with a history, physical examination, and noninvasive testing, which includes laboratory tests, combination scoring indices, and imaging (eg, ultrasonography, transient elastography). Liver biopsy remains the reference standard for diagnosis. It should be used when results of noninvasive evaluation are indeterminate, when the etiology of liver disease remains unknown, or when the result may alter management. Clinicians should counsel patients about alcohol use, obesity management, and prevention of infection. Drugs with potential for hepatotoxicity should be avoided. Clinical assessment with laboratory tests and calculation of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores should occur every 6 months. Clinicians should evaluate for and manage cirrhosis-related complications, including hepatocellular carcinoma, ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, esophageal varices, and other complications. Evaluation for liver transplantation is indicated for patients with a MELD score of 15 or greater, complications of cirrhosis, or hepatocellular carcinoma.

Case 4. SF is an asymptomatic 55-year-old man with a history of obesity (body mass index 31 kg/m2), hypertension, and nonalcoholic fatty liver disease (NAFLD) who is returning to care after 2 years. Laboratory test results today show a sodium level of 145 mEq/L, creatinine level of 1.1 mg/dL, aspartate aminotransferase (AST) level of 45 U/L, alanine aminotransferase (ALT) level of 40 U/L, platelet count of 90,000/mcL, international normalized ratio (INR) of 1.34, albumin level of 3.8 g/dL, and total bilirubin level of 0.4 mg/dL. Hepatic nodularity and mild splenomegaly are identified on ultrasonography.

Cirrhosis, which is the result of chronic liver injury, is associated with significant morbidity and mortality, as well as individual and systemic costs and burdens. Between 1999 and 2016, annual US deaths attributable to cirrhosis increased 65%, and rates of mortality secondary to hepatocellular carcinoma, a cirrhosis-related complication, doubled.97 In the United States, younger adults (ie, ages 25 to 34 years) and White, Native American, and Hispanic individuals have experienced the greatest increases in cirrhosis-related mortality, which is primarily alcohol-related.

Although mortality rates associated with alcoholic liver disease and nonalcoholic fatty liver disease (NAFLD) have been increasing since 2013, the age-standardized mortality rate from hepatitis C has decreased over this same period as a result of effective treatment with direct-acting antiviral drugs.98

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