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Management of ascites and hepatorenal syndrome

  • Special Issue - Portal Hypertension
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Abstract

Ascites represents the most common decompensating event in patients with liver cirrhosis. The appearance of ascites is strongly related to portal hypertension, which leads to splanchnic arterial vasodilation, reduction of the effective circulating volume, activation of endogenous vasoconstrictor systems, and avid sodium and water retention in the kidneys. Bacterial translocation further worsens hemodynamic alterations of patients with cirrhosis and ascites. The first-line treatment of uncomplicated ascites is a moderate sodium-restricted diet combined with diuretic treatment. In patients who develop refractory ascites, paracentesis plus albumin represents the most feasible option. Transjugular intrahepatic portosystemic shunt placement is a good alternative for selected patients. Other treatments such as vasoconstrictors and automated low-flow pumps are two potential options still under investigations. Ascites is associated with a high risk of developing further complications of cirrhosis such as dilutional hyponatremia, spontaneous bacterial peritonitis and/or other bacterial infections and acute kidney injury (AKI). Hepatorenal syndrome (HRS) is the most life-threatening type of AKI in patients with cirrhosis. The most appropriate medical treatment in patients with AKI-HRS is the administration of vasoconstrictors plus albumin. Finally, ascites impairs both the quality of life and survival in patients with cirrhosis. Thus, all patients with ascites should be evaluated for the eligibility for liver transplantation. The aim of this article is to review the management of patients with cirrhosis, ascites and HRS.

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*Modified from Ref. [81]

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Abbreviations

AKI:

Acute kidney injury

HRS:

Hepatorenal syndrome

ECV:

Effective circulating volume

SNS:

Sympathetic nervous system

RAAS:

Renin angiotensin aldosterone system

PAMPs:

Pathogen-associated molecular patterns

NO:

Nitric oxide

CO:

Carbon monoxide

SBP:

Spontaneous bacterial peritonitis

SAAG:

Serum albumin ascites gradient

HBV:

Hepatitis B virus

HCV:

Hepatitis C virus

RCT:

Randomized controlled trial

PICD:

Paracentesis induced circulatory dysfunction

TIPS:

Transjugular intrahepatic portosystemic shunt

LT:

Liver transplantation

MELD:

Model of end stage liver disease

GFR:

Glomerular filtration rate

AVP:

Arginine vasopressin

FDA:

Food and Drug Administration

MDR:

Multi-drug resistant

TNF-α:

Tumor necrosis factor alpha

iNOS:

Inducible nitric oxide synthase

ACLF:

Acute on chronic liver failure

sCr:

Serum creatinine

TLR4:

Toll like receptor 4

LPS:

Lipopolysaccharide

DAMPs:

Danger associated molecular patterns

NSAIDs:

Non-steroidal anti-inflammatory drugs

ATN:

Acute tubular necrosis

NGAL:

Neutrophil gelatinase-associated lipocalin

RRT:

Renal replacement therapy

SKL:

Simultaneous kidney liver transplantation

KDIGO:

Kidney disease improving global outcomes

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  1. Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy

    Salvatore Piano, Marta Tonon & Paolo Angeli

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  1. Salvatore Piano
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  2. Marta Tonon
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Correspondence to Paolo Angeli.

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S.P. and M.T. have nothing to disclose. P.A.: scientific advisory board of Sequana Medical.

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Piano, S., Tonon, M. & Angeli, P. Management of ascites and hepatorenal syndrome. Hepatol Int 12 (Suppl 1), 122–134 (2018). https://doi.org/10.1007/s12072-017-9815-0

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