End stage liver disease is a condition in which the liver is unable to support life without extrinsic supports and loses its ability to cope with the metabolic and toxic demands placed by the body. It manifests as encephalopathy, ascites, renal failure, decreased oxygenation, low sodium and low blood pressures. It is also defined by the MELD scores to identify patients who will need Liver transplantation for increasing survival.The key principle is to avoid a second or third insult from which the patient may lose the opportunity to recover.

# 1 Keep up your protein intake: 

Never cut down the protein intake of the patient. Indian patients are malnourished by the time we see them in the clinic. It is important to continue the protein intake as much as possible. In our center, we rarely restrict any kind of protein intake. In fact, we supplement most of our patients with protein supplements to tide over the malnutrition. Good results for treatment of liver disease comes from good nutrition.

# 2 Keep your salt intake down:

It is important for the patient to keep the intake of salt especially when there is fluid accumulation in the belly. It is mandatory if you have fluid in your feet as well. The total amount of salt that can be taken is 5 g of Sodium Chloride, which has 2 g of Sodium. This will be a teaspoon of salt in a day. If you cook the food without salt, you can add the salt to your favourite food and increase your intake. 

# 3 Keep walking: 

Good muscle tone and bulk translates into better recovery. We always recommend that our patients continue good physical therapy to ensure good results. Tiredness and apathy is common in patients with end stage liver disease, but with encouragement and professional support, every patient can prevent loss of muscle tone and bulk. When you reach a point in which complications from liver disease happens, start good exercises, especially walking and climbing stairs.

# 4 Prevent infections: 

There are preventable infections in cirrhotics that easily kill patients. Infections in cirrhotics fall into one of the following categories: Skin infections, respiratory infections, urinary tract infections, blood stream infection and infection of the ascitic fluid. Supple skin is easily maintained and prevents itching. it also allows you to examine the skin surfaces closely and treat infections at the earliest possible stage. Supple and moist skin will prevent skin break down and infections. Respiratory infection can be prevented by using incentive spirometry and allows ciliary clearance of the respiratory tract. Avoidance of fever contacts, especially with cough and cold will also reduce the risk of picking up an infection. Avoid all catheters in your urinary bladder and any IV lines for more than 2 days unless it is absolutely necessary for medical management. Ascites infection can be reduced by taking antibiotic prophylaxis as determined by your medical team.

# 5 Medical compliance:

Most of the cirrhotics do not become seriously ill all of a sudden. Failure to comply with medical advise and failure to take appropriate medications is the most common reason for life threatening complications. As a patient with end stage liver disease, small complications may pull you down to death's door and if it is because of non compliance with medications, it will be most unfortunate. Time all your living activities around your medical care till the time of transplant. This will ensure that the preventable complications will be avoided and problems identified at the earliest. If your MELD > 20, it is important that you follow up with your liver specialist every month.

# 6 Avoid Alcohol: 

This sounds obvious to patients whose liver disease is from alcohol intake. It is equally important that patients with liver disease due to other conditions avoid alcohol intake. Alcohol is toxic to liver cells and will interfere with medications and may lead to instability in your liver disease. So the best policy would be to avoid even small quantities of alcohol.

# 7 HCC screening: 

In India, we find that HCC screening is not done for most patients with cirrhosis and the HCC we diagnose in patients with cirrhosis are larger and more advanced. HCC screening is mandatory in developed nations, when it can be cured. It is important that you are screened for HCC every 6 months with ultrasound and a blood test that checks your level of alfa fetoprotein.

# 8 Never lose hope: 

This may sound silly. But I find it very common to see patients who seem to have given up and this leads to low compliance and failure of treatments. This immediately strengthens the argument that liver disease treatments have poor results. Nothing can be more wrong than this attitude. Liver disease patients have been having good survival in most of the countries with the arrival of transplantation. Results in India are nearing such outcomes. So keep up your spirits. the best days in your life are yet to come.

Whichever stage of liver disease you are in, follow these instructions to improve your care. Allow your hepatologist to fine tune these recommendations and follow them diligently. The best days of your life are today and the ones you can find your tomorrow.