Cirrhosis: A GOLD-Style Practical Guideline

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.platypus import Flowable

# ── Color palette ──────────────────────────────────────────────────────────────
NAVY      = colors.HexColor("#1B3A6B")
TEAL      = colors.HexColor("#1A7A8A")
AMBER     = colors.HexColor("#E07B00")
LIGHT_BG  = colors.HexColor("#EEF4F7")
WARN_BG   = colors.HexColor("#FFF4E0")
GREEN_BG  = colors.HexColor("#E8F5E9")
RED_BG    = colors.HexColor("#FDECEA")
WHITE     = colors.white
DARK_TEXT = colors.HexColor("#1A1A2E")
MID_GRAY  = colors.HexColor("#555555")
LIGHT_GRAY= colors.HexColor("#CCCCCC")

# ── Document ───────────────────────────────────────────────────────────────────
OUTPUT = "/tmp/workspace/cirrhosis-guide/Cirrhosis_Practical_Guidelines.pdf"
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    topMargin=1.8*cm, bottomMargin=1.8*cm,
    leftMargin=1.6*cm, rightMargin=1.6*cm,
    title="Cirrhosis: Practical Management Guidelines",
    author="Orris Medical Reference"
)

W, H = A4
CW = W - 3.2*cm   # content width

# ── Styles ─────────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def ps(name, parent="Normal", **kw):
    return ParagraphStyle(name, parent=base[parent], **kw)

S = {
    "title"  : ps("title",  fontSize=22, textColor=WHITE, alignment=TA_CENTER,
                   leading=28, spaceAfter=4, fontName="Helvetica-Bold"),
    "sub"    : ps("sub",    fontSize=11, textColor=colors.HexColor("#CCE8EF"),
                   alignment=TA_CENTER, leading=14, fontName="Helvetica"),
    "h1"     : ps("h1",     fontSize=13, textColor=WHITE, fontName="Helvetica-Bold",
                   leading=16, spaceBefore=6, spaceAfter=2),
    "h2"     : ps("h2",     fontSize=10.5, textColor=NAVY, fontName="Helvetica-Bold",
                   leading=13, spaceBefore=6, spaceAfter=2),
    "body"   : ps("body",   fontSize=9, textColor=DARK_TEXT, leading=13,
                   spaceAfter=3, fontName="Helvetica"),
    "small"  : ps("small",  fontSize=8, textColor=MID_GRAY, leading=11,
                   fontName="Helvetica"),
    "bullet" : ps("bullet", fontSize=9, textColor=DARK_TEXT, leading=13,
                   leftIndent=10, firstLineIndent=-10, spaceAfter=2,
                   fontName="Helvetica"),
    "warn"   : ps("warn",   fontSize=8.5, textColor=colors.HexColor("#7A3800"),
                   leading=12, fontName="Helvetica-Bold"),
    "code"   : ps("code",   fontSize=8, textColor=NAVY, leading=12,
                   fontName="Courier", leftIndent=6),
    "footer" : ps("footer", fontSize=7.5, textColor=MID_GRAY,
                   alignment=TA_CENTER, fontName="Helvetica"),
}

# ── Header / Footer callbacks ──────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # top stripe
    canvas.setFillColor(NAVY)
    canvas.rect(0, H - 1*cm, W, 1*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(WHITE)
    canvas.drawString(1.6*cm, H - 0.65*cm, "Cirrhosis: Practical Management Guidelines")
    canvas.drawRightString(W - 1.6*cm, H - 0.65*cm, "Based on EASL CPG · Baveno VII · Chinese Guidelines 2025")
    # bottom stripe
    canvas.setFillColor(LIGHT_GRAY)
    canvas.rect(0, 0, W, 0.7*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 7.5)
    canvas.setFillColor(MID_GRAY)
    canvas.drawCentredString(W/2, 0.22*cm,
        f"For clinical reference only – verify against current local guidelines | Page {doc.page}")
    canvas.restoreState()

def on_first_page(canvas, doc):
    on_page(canvas, doc)

# ── Helper: section header banner ─────────────────────────────────────────────
def section_banner(text, color=TEAL):
    data = [[Paragraph(text, S["h1"])]]
    t = Table(data, colWidths=[CW])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return t

def note_box(text, bg=WARN_BG, text_style="warn"):
    data = [[Paragraph(text, S[text_style])]]
    t = Table(data, colWidths=[CW])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("RIGHTPADDING",  (0,0), (-1,-1), 8),
        ("BOX", (0,0), (-1,-1), 0.5, AMBER),
    ]))
    return t

def std_table(headers, rows, col_widths=None, header_color=NAVY):
    data = [[Paragraph(h, ps("th", fontSize=8.5, textColor=WHITE,
                              fontName="Helvetica-Bold", leading=11)) for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), ps("td", fontSize=8.5, textColor=DARK_TEXT,
                                           fontName="Helvetica", leading=12)) for c in row])
    if col_widths is None:
        col_widths = [CW / len(headers)] * len(headers)
    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = [
        ("BACKGROUND", (0,0), (-1,0), header_color),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [WHITE, LIGHT_BG]),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("GRID", (0,0), (-1,-1), 0.3, LIGHT_GRAY),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
    ]
    t.setStyle(TableStyle(style))
    return t

def B(text):
    return f"<b>{text}</b>"

def bullet(text):
    return Paragraph(f"• {text}", S["bullet"])

# ── Build story ────────────────────────────────────────────────────────────────
story = []
sp = lambda n=1: Spacer(1, n*3*mm)

# ══════════════════════════════════════════════════════════════════════════════
# COVER BLOCK
# ══════════════════════════════════════════════════════════════════════════════
cover_data = [
    [Paragraph("CIRRHOSIS", S["title"])],
    [Paragraph("Practical Management Guidelines", S["sub"])],
    [Paragraph("A GOLD-style Quick Reference · Based on EASL CPG, Baveno VII & Chinese Guidelines 2025", S["sub"])],
]
cover = Table(cover_data, colWidths=[CW])
cover.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 10),
    ("BOTTOMPADDING", (0,0), (-1,-1), 10),
    ("LEFTPADDING",   (0,0), (-1,-1), 12),
    ("RIGHTPADDING",  (0,0), (-1,-1), 12),
    ("ROUNDEDCORNERS", [6]),
]))
story += [cover, sp(2)]

# ══════════════════════════════════════════════════════════════════════════════
# STEP 1 – STAGING
# ══════════════════════════════════════════════════════════════════════════════
story += [section_banner("STEP 1 — Determine the Stage"), sp()]

story += [Paragraph(
    "Cirrhosis follows a 6-stage EASL/Baveno system grouped into three clinical phases. "
    "Use Child-Pugh and MELD-Na for quick bedside classification.",
    S["body"]), sp()]

stage_rows = [
    ["1", "Compensated", "No varices, no ascites", "~1.5%"],
    ["2", "Compensated", "Varices present, no bleeding", "~2%"],
    ["3", "Decompensated", "Ascites (±varices)", "~10%"],
    ["4", "Decompensated", "Variceal bleeding", "~21%"],
    ["5", "Decompensated", "≥2 complications / ACLF", "~87%"],
    ["6", "Decompensated", "Refractory / multi-organ failure", "Very high"],
]
story += [std_table(
    ["Stage", "Phase", "Key Feature", "Annual Mortality"],
    stage_rows,
    col_widths=[1.8*cm, 3.8*cm, 8*cm, 3.2*cm]
), sp()]

# Child-Pugh quick table
cp_rows = [
    ["Child-Pugh A (5–6 pts)",  "Compensated",           "Annual mortality ~1–2%"],
    ["Child-Pugh B (7–9 pts)",  "Early decompensated",   "Annual mortality ~10–20%"],
    ["Child-Pugh C (10–15 pts)","Advanced decompensated","Annual mortality >50%"],
]
story += [
    Paragraph(B("Child-Pugh Quick Classification"), S["h2"]),
    std_table(["Score", "Phase", "Prognosis"], cp_rows,
              col_widths=[4.5*cm, 5*cm, 7.3*cm], header_color=TEAL),
    sp(),
    note_box("⚠  MELD-Na ≥ 15 → Refer to liver transplant centre. "
             "MELD-Na ≥ 20 → Priority listing."),
    sp(2)
]

# ══════════════════════════════════════════════════════════════════════════════
# STEP 2 – TREAT THE CAUSE
# ══════════════════════════════════════════════════════════════════════════════
story += [section_banner("STEP 2 — Treat the Underlying Etiology (Always First)"), sp()]

etiol_rows = [
    ["HBV cirrhosis",        "Entecavir 0.5 mg/day OR Tenofovir TDF/TAF — lifelong, even after HBsAg clearance"],
    ["HCV cirrhosis",        "DAAs: SOF/VEL (pan-genotypic, 12 wks) or GLE/PIB (8 wks) if compensated; specialist referral if decompensated"],
    ["Alcohol-related (ALD)","Complete abstinence; baclofen 5–10 mg TID or naltrexone 50 mg/day to support abstinence"],
    ["MASLD/MASH",           "Weight loss 7–10%; treat metabolic syndrome; resmetirom 80–100 mg/day if MASH + fibrosis ≥F2"],
    ["Autoimmune hepatitis", "Prednisolone 0.5–1 mg/kg/day + azathioprine 1–2 mg/kg/day; maintenance to prevent flares"],
    ["PBC",                  "UDCA 13–15 mg/kg/day; add obeticholic acid or fibrates if inadequate response"],
    ["Wilson's disease",     "Penicillamine 1–1.5 g/day OR Trientine 750–1500 mg/day; zinc maintenance"],
    ["Hemochromatosis",      "Phlebotomy weekly until ferritin <50 mcg/L; maintenance phlebotomy every 2–4 months"],
]
story += [
    std_table(["Etiology", "Treatment"], etiol_rows,
              col_widths=[4.5*cm, 12.3*cm], header_color=TEAL),
    sp(2)
]

# ══════════════════════════════════════════════════════════════════════════════
# STEP 3 – COMPLICATIONS
# ══════════════════════════════════════════════════════════════════════════════
story += [section_banner("STEP 3 — Complication-Based Pharmacotherapy"), sp()]

# A. Varices
story += [Paragraph("A.  Varices / Portal Hypertension", S["h2"])]
varice_rows = [
    ["Primary prophylaxis\n(compensated + varices)", 
     "Carvedilol 6.25 mg/day (preferred) OR Propranolol 20–40 mg BID\nTitrate to resting HR ~55 bpm. Target: HVPG <12 mmHg"],
    ["Acute variceal bleed",
     "Terlipressin 1–2 mg IV q4–6h (1st choice) OR Somatostatin 250 mcg bolus → 250 mcg/h infusion\n+ Ceftriaxone 1 g IV/day × 7 days (all patients, reduces SBP/mortality)"],
    ["Secondary prophylaxis\n(post-bleed)",
     "NSBB (carvedilol or propranolol) + Endoscopic Variceal Ligation (EVL) combined\nNSBB alone if EVL not available"],
    ["Refractory / rescue",
     "TIPS (transjugular intrahepatic portosystemic shunt)\nSengstaken-Blakemore tube as temporary bridge only"],
    ["Statins (adjunct)",
     "Simvastatin 20 mg/day (max 40 mg in Child-Pugh A; max 20 mg in Child-Pugh B; avoid in C)\nReduces portal pressure, HCC risk (Baveno VII B.2 recommendation)"],
]
story += [
    std_table(["Situation", "Treatment"], varice_rows,
              col_widths=[4.5*cm, 12.3*cm], header_color=NAVY),
    sp(1.5)
]

# B. Ascites
story += [Paragraph("B.  Ascites", S["h2"])]
asc_rows = [
    ["Grade 1 (mild)",     "Sodium restriction < 2 g/day (88 mmol). Avoid NSAIDs."],
    ["Grade 2 (moderate)", "Spironolactone 100 mg/day → titrate to max 400 mg/day\n+ Furosemide 40 mg/day → max 160 mg/day (maintain 100:40 ratio)\nMonitor electrolytes every 1–2 weeks initially"],
    ["Grade 3 (tense)",    "Large-volume paracentesis (LVP) + Albumin 8 g per litre removed\nContinue diuretics if tolerated"],
    ["Refractory ascites", "Discontinue NSBBs if MAP <65 mmHg or AKI\nMidodrine 7.5–15 mg TID + Octreotide 100–200 mcg TID (oral)\nTIPS in eligible patients (Child-Pugh <13, no HE)\nLong-term albumin: 40 g q2 weeks (ANSWER trial — B.2 recommendation)"],
    ["Hyponatraemia\n(Na <130 mmol/L)", "Fluid restrict to 1–1.5 L/day; consider tolvaptan (specialist use);\ncorrect cautiously — avoid rapid correction"],
]
story += [
    std_table(["Severity", "Treatment"], asc_rows,
              col_widths=[4.5*cm, 12.3*cm], header_color=NAVY),
    sp(1.5)
]

# C. SBP
story += [Paragraph("C.  Spontaneous Bacterial Peritonitis (SBP)", S["h2"])]
sbp_rows = [
    ["Active SBP\n(PMN ≥250/mm³)",
     "Cefotaxime 2 g IV q8h × 5 days (or Ceftriaxone 1–2 g IV/day)\n+ Albumin 1.5 g/kg day 1, then 1 g/kg day 3 → reduces HRS, improves survival"],
    ["Primary prophylaxis\n(high-risk patients)",
     "Protein <1.5 g/dL AND [CTP ≥9 OR Bilirubin ≥3 mg/dL OR Cr ≥1.2 OR Na ≤130]:\nNorfloxacin 400 mg/day OR Trimethoprim-sulfamethoxazole 1 DS/day"],
    ["Secondary prophylaxis\n(after SBP episode)",
     "Norfloxacin 400 mg/day (lifelong)\nIf quinolone-resistant prevalence high: IV Ceftriaxone 1 g/day in hospitalised patients"],
]
story += [
    std_table(["Situation", "Treatment"], sbp_rows,
              col_widths=[4.5*cm, 12.3*cm], header_color=NAVY),
    sp(1.5)
]

# D. HE
story += [Paragraph("D.  Hepatic Encephalopathy (HE)", S["h2"])]
he_rows = [
    ["Acute episode – first line",
     "Lactulose 25–45 mL q6–8h PO/NG — titrate to 2–3 soft stools/day\nIdentify + treat precipitant: GI bleed, infection, constipation, hyponatraemia, medications"],
    ["Acute episode – second line",
     "Rifaximin 550 mg BID (add to lactulose)\nL-ornithine L-aspartate (LOLA) 20 g IV/day or 6 g TID oral"],
    ["Prevention of recurrence",
     "Lactulose long-term + Rifaximin 550 mg BID (long-term) — reduces hospitalisation by ~60%\nZinc 220 mg/day sulfate (often deficient)"],
    ["Grade 3–4 HE (ICU)",
     "Intubate for airway protection; avoid benzodiazepines\nMannitol if cerebral oedema suspected; ammonia-lowering measures"],
]
story += [
    std_table(["Situation", "Treatment"], he_rows,
              col_widths=[4.5*cm, 12.3*cm], header_color=NAVY),
    sp(1.5)
]

# E. HRS
story += [Paragraph("E.  Hepatorenal Syndrome (HRS-AKI)", S["h2"])]
hrs_rows = [
    ["HRS-AKI diagnosis",
     "Cr rise ≥0.3 mg/dL in 48h OR ≥50% from baseline. No structural kidney disease.\nNo improvement after 48h diuretic withdrawal + albumin 1 g/kg/day"],
    ["First-line treatment",
     "Terlipressin 1 mg IV q4–6h (titrate to 2 mg q4h) + Albumin 20–40 g/day\nContinue up to 14 days; goal: Cr < 1.5 mg/dL"],
    ["Where terlipressin unavailable",
     "Norepinephrine 0.5–3 mg/h IV (ICU) + Albumin\nOR Midodrine 7.5–15 mg TID + Octreotide 100–200 mcg TID + Albumin (less effective)"],
    ["Renal replacement / definitive",
     "TIPS in selected patients; liver transplant is the definitive cure\nAvoid nephrotoxins; stop diuretics, NSBBs, ACEi/ARBs"],
]
story += [
    std_table(["Situation", "Treatment"], hrs_rows,
              col_widths=[4.5*cm, 12.3*cm], header_color=NAVY),
    sp(1.5)
]

# F. HCC surveillance
story += [Paragraph("F.  HCC Surveillance (All Cirrhosis Patients)", S["h2"])]
hcc_rows = [
    ["All cirrhosis patients",       "Liver ultrasound + AFP every 6 months"],
    ["High-risk (HBV/HCV cirrhosis)","Consider multiphasic CT or MRI annually if US quality poor"],
    ["Nodule ≥1 cm on US",           "Contrast-enhanced multiphasic CT or MRI (LI-RADS classification)"],
    ["Confirmed HCC",                "Refer to multidisciplinary HCC team per local/regional guidelines"],
]
story += [
    std_table(["Population", "Action"], hcc_rows,
              col_widths=[6*cm, 10.8*cm], header_color=TEAL),
    sp(2)
]

# ══════════════════════════════════════════════════════════════════════════════
# STEP 4 – DRUGS TO AVOID
# ══════════════════════════════════════════════════════════════════════════════
story += [section_banner("STEP 4 — Drugs to Avoid in Cirrhosis", color=colors.HexColor("#B71C1C")), sp()]

avoid_rows = [
    ["NSAIDs (ibuprofen, naproxen, etc.)",  "Precipitate AKI, GI bleeding, worsen portal hypertension"],
    ["Aminoglycosides (gentamicin)",         "High nephrotoxicity risk in cirrhosis"],
    ["ACE inhibitors / ARBs",               "Can precipitate HRS in decompensated disease; use only if essential"],
    ["Benzodiazepines",                      "Precipitate / worsen hepatic encephalopathy"],
    ["Metformin",                            "Lactic acidosis risk; avoid in Child-Pugh C / AKI"],
    ["High-dose opioids",                    "Worsen HE; reduce dose and frequency if unavoidable"],
    ["Long-term PPIs (without indication)",  "Associated with increased SBP and C. difficile risk"],
    ["Herbal supplements / traditional meds","Many hepatotoxic; take full medication history every visit"],
    ["Statins in Child-Pugh C",             "Benefit not proven; myopathy and hepatotoxicity risk"],
    ["Nitric oxide donors (nitroglycerin)",  "Worsen hypotension in decompensated cirrhosis"],
]
story += [
    std_table(["Drug / Class", "Reason to Avoid"], avoid_rows,
              col_widths=[6.5*cm, 10.3*cm], header_color=colors.HexColor("#B71C1C")),
    sp(2)
]

# ══════════════════════════════════════════════════════════════════════════════
# STEP 5 – SUPPORTIVE CARE
# ══════════════════════════════════════════════════════════════════════════════
story += [section_banner("STEP 5 — Supportive Measures (Every Patient)"), sp()]

support = [
    ("Nutrition",          "1.2–1.5 g protein/kg/day. Small frequent meals (4–6/day). Bedtime snack (35 g carbohydrate) to prevent overnight catabolism. High-calorie diet 35–40 kcal/kg/day."),
    ("Salt restriction",   "< 2 g/day sodium if ascites present. No need for water restriction unless Na < 130 mmol/L."),
    ("Alcohol",            "Complete and permanent abstinence regardless of etiology."),
    ("Vaccinations",       "Hepatitis A + B (if non-immune), pneumococcal (PCV13/PPSV23), annual influenza, COVID-19."),
    ("Exercise",           "Moderate aerobic + resistance exercise — reduces sarcopenia, improves prognosis."),
    ("Zinc",               "Supplement 220 mg zinc sulfate/day if deficient (common in cirrhosis)."),
    ("Muscle cramps",      "Quinine sulfate 200–300 mg/night OR albumin infusion (if regular cramps with hypoalbuminaemia)."),
    ("Psychosocial",       "Screen for depression and anxiety. Alcohol/substance use counselling. Liver transplant eligibility assessment early."),
]
sup_rows = [[Paragraph(B(k), S["body"]), Paragraph(v, S["body"])] for k, v in support]
sup_table = Table(sup_rows, colWidths=[4*cm, 12.8*cm])
sup_table.setStyle(TableStyle([
    ("ROWBACKGROUNDS", (0,0), (-1,-1), [WHITE, LIGHT_BG]),
    ("TOPPADDING",    (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("RIGHTPADDING",  (0,0), (-1,-1), 6),
    ("GRID", (0,0), (-1,-1), 0.3, LIGHT_GRAY),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story += [sup_table, sp(2)]

# ══════════════════════════════════════════════════════════════════════════════
# PAGE 2 – QUICK REFERENCE CARD
# ══════════════════════════════════════════════════════════════════════════════
story += [PageBreak()]

story += [section_banner("QUICK REFERENCE CARD — At-a-Glance Algorithm"), sp()]

algo_lines = [
    "DIAGNOSE CIRRHOSIS",
    "       ↓",
    "STAGE IT  →  Child-Pugh A/B/C  +  MELD-Na",
    "       ↓",
    "TREAT THE CAUSE FIRST (HBV/HCV antivirals, abstinence, UDCA, etc.)",
    "       ↓",
    "CHECK FOR COMPLICATIONS:",
    "",
    "  Varices?         →  NSBB (carvedilol 6.25 mg/day) for prophylaxis",
    "  Acute bleed?     →  Terlipressin IV + ceftriaxone + endoscopy",
    "  Ascites?         →  Spironolactone ± furosemide → LVP + albumin if tense",
    "  SBP?             →  Cefotaxime IV + albumin day 1 & 3 → norfloxacin prophylaxis",
    "  Encephalopathy?  →  Lactulose + find precipitant → add rifaximin",
    "  HRS-AKI?         →  Terlipressin + albumin (stop diuretics, ACEi, NSAIDs)",
    "  HCC screen       →  US + AFP every 6 months (all patients)",
    "",
    "  MELD-Na ≥ 15     →  REFER TO TRANSPLANT CENTRE",
    "",
    "ALWAYS AVOID: NSAIDs · Aminoglycosides · ACEi/ARBs (decompensated) · Benzodiazepines",
]
for line in algo_lines:
    story += [Paragraph(line, S["code"])]
story += [sp(2)]

# Monitoring table
story += [
    Paragraph(B("Routine Monitoring Schedule"), S["h2"]),
    sp()
]
mon_rows = [
    ["All compensated",       "Every 6 months", "LFTs, FBC, creatinine, INR, AFP + liver USS"],
    ["Ascites on diuretics",  "Every 1–4 weeks initially", "U&E, creatinine (adjust diuretics by response)"],
    ["Post-SBP prophylaxis",  "Every 3 months", "Culture if fever; check renal function"],
    ["HBV/HCV on antivirals", "Every 3–6 months", "Viral load, LFTs, HBsAg (HBV)"],
    ["Transplant listed",     "Every 3 months", "Full workup; MELD recalculation"],
    ["Child-Pugh B/C",        "Every 3 months", "Full LFTs, ammonia if HE symptoms, electrolytes"],
]
story += [
    std_table(["Patient Group","Frequency","What to Check"], mon_rows,
              col_widths=[4.5*cm, 4*cm, 8.3*cm], header_color=TEAL),
    sp(2)
]

# Referral indications
story += [
    Paragraph(B("Indications for Urgent Specialist Referral"), S["h2"]), sp(),
]
ref_bullets = [
    "First episode of decompensation (ascites, encephalopathy, variceal bleed, jaundice)",
    "MELD-Na ≥ 15 → transplant assessment",
    "AKI in cirrhosis (creatinine rise ≥ 0.3 mg/dL)",
    "Suspected HRS (no improvement with volume expansion)",
    "New or progressive HCC on surveillance",
    "Recurrent SBP or treatment-refractory SBP",
    "ACLF (acute-on-chronic liver failure) — ICU-level care",
    "Refractory ascites not responding to diuretics",
]
for r in ref_bullets:
    story += [bullet(r)]
story += [sp(2)]

# Sources
story += [
    HRFlowable(color=LIGHT_GRAY, thickness=0.5, width="100%"), sp(),
    Paragraph(B("Key Sources"), S["h2"]),
    Paragraph("1. EASL Clinical Practice Guidelines: Management of patients with decompensated cirrhosis. "
              "J Hepatol 2018;69:406–460.", S["small"]),
    Paragraph("2. Baveno VII Consensus — Renewing consensus in portal hypertension. "
              "J Hepatol 2022;76(4):959–974.", S["small"]),
    Paragraph("3. Chinese Guidelines for Clinical Diagnosis, Treatment, and Management of Cirrhosis (2025). "
              "J Clin Transl Hepatol. PMC12872386.", S["small"]),
    Paragraph("4. AASLD Practice Guidance: Complications of cirrhosis. Hepatology 2021–2024.", S["small"]),
    sp(),
    note_box("This document is a clinical reference summary only. Always verify doses and recommendations "
             "against current local guidelines and individual patient factors. Not a substitute for specialist care."),
]

# ── Build ──────────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=on_first_page, onLaterPages=on_page)
print(f"PDF written to {OUTPUT}")