Crocombe, D; O'Brien, A; (2023) Diagnosis and management of ascites and hepatorenal syndrome (acute kidney injury) in cirrhosis. Medicine , 51 (6) pp. 434-439. 10.1016/j.mpmed.2023.03.011.

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Abstract

Ascites is the most common decompensation-defining complication of cirrhosis and represents a watershed moment, with median survival falling from >12 years for compensated cirrhosis to approximately 2 years. Treatment is based on reducing sodium intake and increasing renal sodium excretion with the aldosterone antagonist spironolactone at a starting dose of 100 mg daily, to which 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 in this context; a combination of vasoconstrictors and albumin represents the mainstay of treatment. Terlipressin is the most widely utilized vasoconstrictor, leading to HRS resolution in >50%. The role of transjugular intrahepatic portosystemic shunt (TIPS) insertion or renal replacement therapy for HRS remains uncertain, with further studies needed. Many patients with cirrhotic ascites require regular ascitic drainage every 2–4 weeks, best achieved in outpatient day-case settings. Diuretic medications often require frequent dose adjustment because of coexisting renal impairment. In patients in whom ascites persists despite medical therapy, liver transplantation or TIPS should be considered. Finally, given the poor prognosis for many, it is important, where appropriate, to address end-of-life planning and palliative care in advance.

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