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Chronic liver disease (CLD) is commonly associated with a significant burden of symptoms that should be addressed in the context of treatment of the underlying liver disease. Common liver-disease–associated symptoms, such as pruritus, fatigue/ sleep disorders, volume overload, cramping and pain, and depression and anxiety significantly impact the quality of life in our patients living with CLD. The recognition that symptoms need to be acknowledged and addressed is integral to not only the clinical care of patients but also in the design of research studies that hope to evaluate therapeutic interventions for CLD.1 Furthermore, there has been an increasing focus in our field on the importance of early palliative care involvement for patients with advanced liver disease to optimize symptom management, which is a key component of the first Palliative Care guidance recently developed by the American Association for the Study of Liver Diseases (AASLD).2 Prevalence and types of symptoms among patients with CLD vary by liver disease etiology, liver disease stage, and burden of comorbidities, but universally symptom burden is high among patients with end-stage liver disease (ESLD). For example, per a large systematic review evaluating symptoms drawing data from 80 studies, pain symptoms occurred in 30%–79% of individuals, muscle cramps occurred in 56%–68% of individuals, sleep disturbances occurred in 26%–77%, and psychological symptoms occurred in 4.5%–64% of patients with ESLD.3 Thus there is a need to recognize and systematically address symptom burden, with an approach that tracks symptoms over time and prioritizes symptom management.2 Considerations specific to ESLD should be made before initiating medication therapy, and multidisciplinary care management may be needed to optimize symptoms control, such as the incorporation of physical therapy, behavioral management, and procedural approaches to optimize pain management. Furthermore, studies focused on specific symptom management in patients with ESLD, such as the novel PICCLES trial demonstrating the benefit of a pickle juice intervention on cramp symptoms in individuals living with cirrhosis, are needed.4 In this CLD series, we evaluate our current approaches to the management of commonly occurring symptoms in patients with CLD: pruritus, fatigue/ sleep disorders, volume overload, cramping and pain, and depression and anxiety. Current data on the approach to clinical management of CLD symptoms are discussed for each of these commonly reported symptoms that affect so many of our patients with CLD.
