The Application of Lifestyle Enhancing Validated Integrative Therapies for Everyday Pain in Cirrhosis

For people ages 18 years and up

Patient Inclusion Criteria:

1. Age > 18 years of age.
2. Clinical diagnosis of cirrhosis established by any one of the following:
   1. Liver biopsy consistent with cirrhosis.
   2. Noninvasive evidence of cirrhosis, defined as ≥2 of the following criteria:
      • Imaging (Ultrasound (US), Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)) demonstrating cirrhosis liver morphology (e.g., 'cirrhosis', cirrhotic appearing', 'nodular') with supportive findings (e.g., splenomegaly or recanalized umbilical vein).
        • Transient elastography (TE) (FibroScan) liver stiffness > 12.5 kilopascal (kPa) with IQR/Median <30% or Magnetic resonance elastography > 5.0 kPa
        • Laboratory evidence including AST/platelet ratio index (APRI) >2.0, FIB-4 >2.67 or Platelet count <150 x 10⁹/L.
        • CT, MRI, or Esophagogastroduodenoscopy (EGD) showing the presence of esophageal varices
   3. History of at least one cirrhosis complication, including variceal hemorrhage, hepatocellular carcinoma (HCC), ascites, or hepatic encephalopathy.
3. Liver transplant recipients are eligible if the transplanted cirrhotic allograft meets the above criteria.
4. Chronic pain, defined as a Pain, Enjoyment of Life, and General Activity (PEG) scale score > 4, assessed during screening prior to consent.
5. Ability to ambulate (walk), either independently or with the use of assistive devices.
6. Reliable access to Wi-Fi or cellular data.
7. Ownership of, or reliable access to, a smartphone with the ability and willingness to receive study-related text messages.
8. Ability to speak and read English or Spanish.

Patient Exclusion Criteria:

1. Acute pain due to injury (e.g., surgery, fracture, trauma, burn) within 28 days.
2. Diagnosed or suspected noncirrhotic portal hypertension.
3. Episode of overt hepatic encephalopathy (HE) within 28 days prior to consent.
   1. Overt HE is defined as acute disorientation requiring hospitalization or initiation of HE-directed therapy (e.g., lactulose, fluids, rifaximin) with diagnosis made by a gastroenterologist, hepatologist, or study investigator and resolution following therapy.
4. Model for End-Stage Liver Disease - Na (MELD-Na) score > 25 calculated using the UNOS algorithm.
   1. Participants with MELD-Na > 25 due to clinically stable end-stage renal disease (ESRD) may be eligible if total bilirubin < 5 mg/dL.
5. Advanced hepatocellular carcinoma (HCC) defined as Barcelona Clinic Liver Cancer (BCLC) stage > C, or current treatment with systemic therapy for HCC (e.g., sorafenib, atezolizumab/bevacizumab, durvalumab/tremelimumab, regorafenib, cabozantinib).
6. > 2 paracenteses within 56 days prior to consent.
7. Fontan-associated liver disease without cirrhosis on biopsy.
8. Inpatient hospital admission lasting > 24 hours within 28 days prior to consent.
9. Active metastatic solid malignancy or acute leukemia within 3 years prior to consent.
10. Estimated life expectancy < 1 year, as determined by the study investigator.
11. Planned living donor liver transplantation within 12 weeks of enrollment.
12. Routine meditation practice, defined as meditation occurring weekly or more frequently.
13. Inability to participate in study procedures, including inability to read study materials, cognitive impairment, or psychiatric illness that would preclude participation in the opinion of the investigator.
14. Concurrent enrollment in another nonpharmacologic pain management study or formal pain management program utilizing nonpharmacologic approaches.
15. Deemed unsuitable for participation by the study investigator.
16. Prisoners.

Care Partner Inclusion Criteria

1. Age > 18 years of age.
2. Informal caregiver of a participant enrolled in ALLEVIATE-C
3. Ability to speak and read English or Spanish.

Care Partner Exclusion Criteria

1. Inability to participate in study procedures, including inability to read study materials, cognitive impairment, or psychiatric illness that would preclude participation in the opinion of the investigator.
2. Deemed unsuitable for participation by the study investigator.