Optimizing symptom control in cirrhosis

Cirrhosis, a late-stage form of liver disease in which normal liver tissue is replaced by fibrotic scar tissue, is a growing problem in the United States and around the world. Care of patients with cirrhosis often focuses on monitoring liver function and managing serious complications such as portal hypertension, ascites, and esophageal varices, as well as the symptoms these complications cause.

“Patients with cirrhosis have debilitating symptoms, including fatigue, itching, pain, fluid retention, and cramps,” says Marina Serper, MD, MS, an associate professor of medicine (gastroenterology) at the Perelman School of Medicine. That these symptoms may be under-recognized or undertreated in routine clinical care remains a central issue in cirrhosis management.

As a clinical expert and research leader in cirrhosis management, Dr. Serper hopes to change this. “With proactive symptom monitoring, nonpharmacological interventions, and improvements in care delivery, we can improve quality of life for patients with cirrhosis while also optimizing their health ahead of liver transplant,” she says.

Treating cirrhosis and managing symptoms

Alcohol-associated liver disease remains the most significant cause of cirrhosis. At the same time, another precipitant, metabolic dysfunction-associated steatotic liver disease (MASLD), is rising with increases in obesity. In the US, an estimated 4.5 million adults are currently diagnosed with liver disease according to the National Center for Health Statistics. Nationwide, more than 52,000 adults die from liver disease and cirrhosis each year.

Because the scar tissue of cirrhosis is non-functioning and cannot be reversed, liver transplant is the only definitive treatment for end-stage cirrhosis. But the disease can cause significant symptoms well before a patient becomes a candidate for transplant.

Helping patients with cirrhosis manage the challenges of the disease starts with listening. “I generally approach symptom management by asking a patient to tell me what symptoms are bothering them most and how bad they are on a scale of 1 to 10,” Dr. Serper says. “We try to address some of their symptom needs at every appointment.”

Some of these symptoms can be managed without medications, she says, adding that many patients benefit from de-prescribing of medications that are not providing benefit, including benzodiazepines, anticholinergics, and opioids.

“Approaches such as weight-bearing exercises, increasing protein, and getting better sleep can help control symptoms,” she says. “Working with patients to improve their nutrition and physical strength also supports improved post-transplant outcomes.”

The LiverWatch study: remote monitoring to enhance care

Dr. Serper and her colleagues are involved in research to develop better methods of tracking symptoms in patients with cirrhosis. “Symptom management is important, but it can be challenging. Often there is not enough time in a single visit to address each symptom in detail, and patients may need frequent follow-ups to address them all,” she says.

To engage these issues, Dr. Serper’s recent LiverWatch study aimed to streamline symptom management and improve outcomes through a remote monitoring intervention. All patients were provided with wearable fitness trackers and encouraged to increase their physical activity. Half were randomized to receive care as usual, while half received access to a digital intervention that provided personalized nutrition counseling, cirrhosis education, and incentives to increase physical activity. The digital intervention also helps patients track their symptoms, and those symptoms are shared with the care team.

Certain symptoms trigger a follow-up call from a nurse, who helps patients manage the symptom and escalates care as needed. “Remote monitoring helps patients monitor symptoms between visits, and can help us send patients feedback, encouragement, and useful information about diet and exercise to keep them healthy,” Dr. Serper says.

The clinical trial was recently completed, and the team is now analyzing data from the study. Although it is too soon to report results, Dr. Serper is hopeful that the approach could benefit patients. “One of the barriers to cirrhosis care is that clinicians don’t have enough time to address a lot of these details in every appointment. We feel this program has promise if we can deliver useful, automated content that encourages and educates patients,” she says.

Liver disease care and transplant: referring patients to Penn Medicine

Although remote monitoring is promising, it is not designed to replace regular care from physicians, nor to respond to urgent symptoms. Dr. Serper encourages her colleagues to refer patients with cirrhosis to a specialty center as soon as they show signs of clinical deterioration, regardless of their Model for End-Stage Liver Disease (MELD) score, which governs transplant priority.

“Individuals with symptomatic decompensated liver cirrhosis have an average life expectancy of only two years, but these patients can have low MELD scores,” Dr. Serper notes. Thus, symptoms of decompensation—ascites, encephalopathy, muscle wasting, bleeding varices, and portal gastropathy in the setting of cirrhosis, or new liver cancer—should prompt referral to a transplant center irrespective of the MELD score.

Penn Medicine’s multidisciplinary teams take a proactive approach to cirrhosis care, ensuring patients’ needs are met from early symptom management through liver transplant.

Referrals and consultations

Learn more about liver disease care and liver transplant at Penn Medicine. To refer a patient or consult with a transplant specialist, please call 877-937-7366 or submit a referral through our secure online referral form.