Clinical Practice GuidelinesEASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis
Section snippets
1.1. Evaluation of patients with ascites
Approximately 75% of patients presenting with ascites in Western Europe or the USA have cirrhosis as the underlying cause. For the remaining patients, ascites is caused by malignancy, heart failure, tuberculosis, pancreatic disease, or other miscellaneous causes.
1.2. Diagnosis of ascites
The initial evaluation of a patient with ascites should include history, physical examination, abdominal ultrasound, and laboratory assessment of liver function, renal function, serum and urine electrolytes, as well as an analysis of
2.1. Evaluation of patients with refractory ascites
According to the criteria of the International Ascites Club, refractory ascites is defined as “ascites that cannot be mobilized or the early recurrence of which (i.e., after LVP) cannot be satisfactorily prevented by medical therapy” [11], [56]. The diagnostic criteria of refractory ascites are shown in Table 3.
Once ascites becomes refractory to medical treatment, the median survival of patients is approximately 6 months [7], [56], [57], [58], [59]. As a consequence, patients with refractory
3. Spontaneous bacterial peritonitis
SBP is a very common bacterial infection in patients with cirrhosis and ascites [10], [105], [106], [107]. When first described, its mortality exceeded 90% but it has been reduced to approximately 20% with early diagnosis and treatment [6], [108].
4. Hyponatremia
Hyponatremia is common in patients with decompensated cirrhosis and is related to impaired solute-free water excretion secondary to non-osmotic hypersecretion of vasopressin (the antidiuretic hormone), which results in a disproportionate retention of water relative to sodium retention [163], [164], [165], [166]. Hyponatremia in cirrhosis is arbitrarily defined when serum sodium concentration decreases below 130 mmol/L [163], but reductions below 135 mmol/L should also be considered as
5.1. Definition and diagnosis of hepatorenal syndrome
Hepatorenal syndrome (HRS) is defined as the occurrence of renal failure in a patient with advanced liver disease in the absence of an identifiable cause of renal failure [56]. Thus, the diagnosis is essentially one of exclusion of other causes of renal failure. In 1994 the International Ascites Club defined the major criteria for the diagnosis of HRS and designated HRS into type 1 and type 2 HRS [56]. These were modified in 2007 [192]. The new diagnostic criteria are shown in Table 8. Various
Acknowledgement
The authors would like to thank Nicki van Berckel for her excellent work in the preparation of the manuscript.
Disclosure: Kevin Moore recieved grant/research support from Olsuka. He served as a consultant for the company and was paid for his consulting services.
References (229)
- et al.
Hepatic venous gradient predicts clinical decompensation in patients with compensated cirrhosis
Gastroenterology
(2007) - et al.
Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club
J Hepatol
(2000) - et al.
The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club
Hepatology
(2003) - et al.
Prognostic value of arterial pressure, endogenous vasoactive systems and renal function in cirrhotic patients admitted to the hospital for the treatment of ascites
Gastroenterology
(1988) - et al.
Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A randomized comparative study of efficacy and safety
J Hepatol
(2003) - et al.
Factors associated with poor health-related quality of life of patients with cirrhosis
Gastroenterology
(2001) - et al.
Cirrhosis and muscle cramps: evidence of a causal relationship
Hepatology
(1996) - et al.
Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study
Gastroenterology
(1987) - et al.
Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis
Gastroenterology
(1988) - et al.
Repeated paracentesis and i.v. albumin infusion to treat “tense ascites” in cirrhotic patients: a safe alternative therapy
J Hepatol
(1987)
Paracentesis with dextran 70 vs. paracentesis with albumin in cirrhosis with tense ascites. Results of a randomized study
J Hepatol
Total paracentesis with dextran 40 vs. diuretics in the treatment of ascites in cirrhosis: a randomized controlled study
J Hepatol
Randomized controlled trial comparing albumin, dextran-70 and polygelin in cirrhotic patients with ascites treated by paracentesis
Gastroenterology
Time course of circulatory and humoral effects of rapid total paracentesis in cirrhotic patients with tense, refractory ascites
Gastroenterology
Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis
Gastroenterology
Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites
Hepatology
Worsening of hepatic dysfunction as a consequence of repeated hydroxyethylstarch infusions
J Hepatol
Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double-blind trial of spironolactone versus placebo
J Hepatol
Should bleeding tendency deter abdominal paracentesis?
Dig Liver Dis
Effect of indomethacin and prostaglandin A1 on renal function and plasma renin activity in alcoholic liver disease
Gastroenterology
Acute effects of captopril on systemic and renal hemodynamics and on renal function in cirrhotic patients with ascites
Gastroenterology
Effects of low-dose captopril on renal haemodynamics and function in patients with cirrhosis of the liver
Gastroenterology
Continuous prazosin administration in cirrhotic patients: effects on portal hemodynamics and on liver and renal function
Gastroenterology
Aminoglycoside nephrotoxicity in cirrhosis. Value of urinary beta 2-microglobulin to discriminate functional renal failure from acute tubular damage
Gastroenterology
Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis
Hepatology
External validation of a prognostic model for predicting survival of cirrhotic patients with refractory ascites
Am J Gastroenterol
A model to predict survival in patients with end-stage liver disease
Hepatology
The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts
Gastroenterology
Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters
Hepatology
Modifications of cardiac function in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt (TIPS)
Am J Gastroenterol
The mechanism of the initial natriuresis after transjugular intrahepatic portosystemic shunt
Gastroenterology
Weight gain after transjugular intrahepatic portosystemic shunt is associated with improvement in body composition in malnourished patients with cirrhosis and hypermetabolism
J Hepatol
Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic findings
Gastroenterology
Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial
J Hepatol
Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis
Gastroenterology
The North American study for the treatment of refractory ascites
Gastroenterology
A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites
J Hepatol
Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis
Gastroenterology
Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data
Gastroenterology
Compensated cirrhosis: natural history and prognostic factors
Hepatology
Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis
Hepatology
The systemic circulation in cirrhosis
Alterations of hepatic and splanchnic microvascular exchange in cirrhosis: local factors in the formation of ascites
Bacterial infections, sepsis, and multiorgan failure in cirrhosis
Semin Liver Dis
Prognosis in patients with cirrhosis and ascites
Management of adult patients with ascites due to cirrhosis
Hepatology
The serum–ascites albumin gradient is superior to the exudate–transudate concept in the differential diagnosis of ascites
Ann Intern Med
Limitations of serum creatinine level and creatinine clearance as filtration markers in cirrhosis
Arch Intern Med
Persistent ascites and low sodium identify patients with cirrhosis and low MELD score who are at high risk for early death
Hepatology
Diuretic treatment in decompensated cirrhosis and congestive heart failure: effect of posture
Br Med J
Cited by (1417)
Comparison of nutritional screening and assessment tools for predicting the composite outcome of mortality and complication in cirrhosis
2024, Clinical Nutrition Open ScienceA new clinical and prognostic characterization of the patterns of decompensation of cirrhosis
2024, Journal of HepatologyPost Liver Transplant Renal Dysfunction—Evaluation, Management and Immunosuppressive Practice
2024, Journal of Clinical and Experimental HepatologyPrognosis of spontaneous bacterial peritonitis in patients with hepatocellular carcinoma
2024, American Journal of the Medical SciencesGut-liver axis: Pathophysiological concepts and medical perspective in chronic liver diseases
2024, Seminars in ImmunologyDecompensated liver cirrhosis
2024, Anaesthesia and Intensive Care Medicine
- 1
Correspondence: 7 rue des Battoirs, CH-1205 Geneva, Switzerland. Tel.: +41 22 807 0360; fax: +41 22 328 07 24.
Contributors: Chairman: Pere Ginès; Clinical Practice Guidelines Members: Paolo Angeli, Kurt Lenz, Søren Møller, Kevin Moore, Richard Moreau; Journal of Hepatology Representative: Carlo Merkel; EASL Governing Board Representatives: Helmer Ring-Larsen and Mauro Bernardi; Reviewers: Guadalupe Garcia-Tsao, Peter Hayes.