O'Brien, A; (2019) Diagnosis and management of ascites and hepatorenal syndrome (acute kidney injury) in cirrhosis. Medicine , 47 (12) pp. 828-832. 10.1016/j.mpmed.2019.09.013.

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Abstract

Ascites is the most common complication of cirrhosis and represents a watershed moment, with patients' median survival falling from >12 years for compensated cirrhosis to approximately 2 years. Treatment aims to reduce sodium intake and increase renal sodium excretion with the aldosterone antagonist spironolactone, starting at 100 mg daily; 60% respond. Renal dysfunction affects as many as 20% of hospitalized patients and is a strong predictor of mortality. Liver transplantation represents the best treatment for hepatorenal syndrome (HRS) yet is rarely available, and a combination of vasoconstrictors and albumin represent the mainstay of treatment. Terlipressin is the most widely used vasoconstrictor, leading to HRS resolution in >50% of patients. The role of transjugular intrahepatic portosystemic shunt insertion or renal replacement therapy for HRS remains uncertain, with further studies needed. These patients are very fragile with a high mortality. Many patients require regular ascitic drainage every 2–4 weeks that is best achieved in a day-case setting. Diuretic medication requires frequent dose adjustment because of coexistent renal impairment. Where ascites persists, liver transplantation or TIPPS should be considered. Finally, given the poor prognosis for many patients, it is important to address end-of-life planning and palliation where appropriate.

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