All individuals with cirrhosis should have a liver ultrasound to examine for features of portal hypertension (splenomegaly, reversal of portal vein flow) and to exclude HCC. People with cirrhosis should be assessed for their risk of clinically significant portal hypertension (CSPH). Guidelines now recommend that non-invasive tools be used to triage risk of CSPH. CSPH can be assumed if LSM is > 25 kPa. CSPH can also be diagnosed if LSM is 20–25 kPa and platelet count is < 150 × 109/L or if LSM is 15–20 kPa and platelet count is < 110 × 109/L. People with CSPH should be considered for non-selective beta-blocker (NSBB) therapy as primary prophylaxis to reduce the risk of liver decompensation. People with CSPH who start NSBB therapy do not need a screening gastroscopy. Among people with cirrhosis who do not start NSBB therapy, gastroscopy should be performed to screen for oesophageal varices that need treatment if LSM is ≥ 20 kPa or platelet count is < 150 × 109/L. People living with cirrhosis and who do not require NSBB therapy or screening gastroscopy can be monitored by yearly assessment of LSM and platelet count. If LSM increases (≥ 20 kPa) or platelet count declines (< 150 × 109/L), screening gastroscopy should be performed to look for varices needing treatment.
In the setting of cirrhosis, it is also important to evaluate for markers of hepatic decompensation. Two key groups among those with cirrhosis are:
i) people with Child–Pugh A cirrhosis who have a low albumin level (< 35 g/L) and/or platelets < 100 × 109/L (NS3 protease inhibitors should be avoided in these people due to concerns about increased intrahepatic drug concentrations and secondary toxicity); and
ii) people with true decompensated liver disease — this group should be considered a special population (see Special Populations: Treatment of Decompensated Liver Disease).
All individuals with decompensated liver disease should be assessed by a specialist with experience in managing chronic liver disease and, where appropriate, referred to a liver transplant centre. Indications for assessment by a liver transplant centre include Child–Pugh score ≥ B7, Model for End-Stage Liver Disease (MELD) score ≥ 13 or one of the following clinical events: refractory ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, recurrent or chronic hepatic encephalopathy, small HCC or severe malnutrition (see Supplementary Table 2).
Bone densitometry is also recommended to screen for osteoporosis.
Performance of these screening tests should not delay treatment for HCV infection among people who have been diagnosed with cirrhosis, but they may be scheduled simultaneously or after treatment. Due to the complexity of managing cirrhosis, it is recommended that these people are referred for assessment by a specialist who is an expert in the care of patients with chronic liver disease, and that they are treated in active collaboration with HCV treatment experts.