Journal List > Korean J Gastroenterol > v.72(4) > 1106210

Seo: 2017 Korean Association for the Study of the Liver (KASL) Clinical Practice Guidelines for Ascites and Related Complications: What Has Been Changed from the 2011 KASL Clinical Practice Guidelines?

Abstract

Ascites is a common complication in patients with liver cirrhosis and is the most common cause of hospitalization in these patients. The development of ascites is associated with a poor prognosis in patients with liver cirrhosis with a higher mortality rate than in those without ascites. Furthermore, the presence of cirrhotic ascites is related to the development of various serious complications, such as refractory ascites, spontaneous bacterial peritonitis, acute kidney injury, and hepatorenal syndrome. Therefore, early detection and appropriate management for the development of ascites and their complications is very important in these patients. Recently, there have been significant revisions in the diagnostic criteria and treatment of cirrhotic ascites and their complications. This manuscript reviews these revisions.

Figures and Tables

Fig. 1

Algorithm for the differential diagnosis of ascites. SAAG, serum-ascites albumin gradient; CHF, congestive heart failure; IVC, inferior vena cava; PMN, polymorphonuclear leukocyte.

kjg-72-179-g001
Fig. 2

Treatment of cirrhotic ascites according to the grades of ascites. Grade 1, minimal ascites, which can be detected only by an imaging study, such as abdominal ultrasound; grade 2, moderate ascites which can be identified easily by a visual inspection and palpation; and grade 3, massive or tense ascites with profound distension of the abdomen.

kjg-72-179-g002

Notes

Financial support None.

Conflict of interest None.

References

1. Ginés P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology. 1987; 7:122–128.
crossref
2. Lucena MI, Andrade RJ, Tognoni G, et al. Multicenter hospital study on prescribing patterns for prophylaxis and treatment of complications of cirrhosis. Eur J Clin Pharmacol. 2002; 58:435–440.
crossref
3. Planas R, Montoliu S, Ballesté B, et al. Natural history of patients hospitalized for management of cirrhotic ascites. Clin Gastroenterol Hepatol. 2006; 4:1385–1394.
crossref
4. Suk KT, Baik SK, Yoon JH, et al. Revision and update on clinical practice guideline for liver cirrhosis. Korean J Hepatol. 2012; 18:1–21.
crossref
5. Korean Association for the Study of the Liver. KASL clinical practice guidelines for liver cirrhosis: ascites and related complications. Clin Mol Hepatol. 2018; 24:230–277.
6. Kuiper JJ, de Man RA, van Buuren HR. Review article: management of ascites and associated complications in patients with cirrhosis. Aliment Pharmacol Ther. 2007; 26:Suppl 2. 183–193.
crossref
7. Runyon BA. Care of patients with ascites. N Engl J Med. 1994; 330:337–342.
crossref
8. Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis. 2001; 33:41–48.
crossref
9. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med. 1992; 117:215–220.
crossref
10. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut. 2006; 55:Suppl 6. vi1–vi12.
crossref
11. Santos J, Planas R, Pardo A, 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; 39:187–192.
crossref
12. Angeli P, Dalla Pria M, De Bei E, et al. Randomized clinical study of the efficacy of amiloride and potassium canrenoate in non-azotemic cirrhotic patients with ascites. Hepatology. 1994; 19:72–79.
crossref
13. Arroyo V, Ginès P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International ascites club. Hepatology. 1996; 23:164–176.
14. Rössle M, Ochs A, Gülberg V, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med. 2000; 342:1701–1707.
crossref
15. Azoulay D, Castaing D, Dennison A, Martino W, Eyraud D, Bismuth H. Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: preliminary report of a prospective study. Hepatology. 1994; 19:129–132.
crossref
16. Michl P, Gülberg V, Bilzer M, Waggershauser T, Reiser M, Gerbes AL. Transjugular intrahepatic portosystemic shunt for cirrhosis and ascites: effects in patients with organic or functional renal failure. Scand J Gastroenterol. 2000; 35:654–658.
crossref
17. Seo JH, Kim SU, Park JY, et al. Predictors of refractory ascites development in patients with hepatitis B virus-related cirrhosis hospitalized to control ascitic decompensation. Yonsei Med J. 2013; 54:145–153.
crossref
18. Heuman DM, Abou-Assi SG, Habib A, et al. Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology. 2004; 40:802–810.
crossref
19. Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol. 1993; 18:353–358.
crossref
20. Tandon P, Garcia-Tsao G. Bacterial infections, sepsis, and multiorgan failure in cirrhosis. Semin Liver Dis. 2008; 28:26–42.
crossref
21. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010; 53:397–417.
22. Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology. 1990; 12(4 Pt 1):710–715.
crossref
23. Soriano G, Castellote J, Alvarez C, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010; 52:39–44.
crossref
24. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology. 1990; 98:127–133.
crossref
25. Runyon BA, Hoefs JC. Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. Hepatology. 1984; 4:447–450.
crossref
26. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007; 132:1261–1269.
crossref
27. Wu SS, Lin OS, Chen YY, Hwang KL, Soon MS, Keeffe EB. Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. J Hepatol. 2001; 34:215–221.
crossref
28. Rimola A, García-Tsao G, Navasa M, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International ascites club. J Hepatol. 2000; 32:142–153.
29. Piano S, Fasolato S, Salinas F, et al. The empirical antibiotic treatment of nosocomial spontaneous bacterial peritonitis: results of a randomized, controlled clinical trial. Hepatology. 2016; 63:1299–1309.
crossref
30. Fernández J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012; 55:1551–1561.
crossref
31. Cheong HS, Kang CI, Lee JA, et al. Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis. Clin Infect Dis. 2009; 48:1230–1236.
crossref
32. Fernández J, Tandon P, Mensa J, Garcia-Tsao G. Antibiotic prophylaxis in cirrhosis: good and bad. Hepatology. 2016; 63:2019–2031.
crossref
33. Jalan R, Fernandez J, Wiest R, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol. 2014; 60:1310–1324.
crossref
34. Wiest R, Krag A, Gerbes A. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut. 2012; 61:297–310.
crossref
35. Follo A, Llovet JM, Navasa M, et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology. 1994; 20:1495–1501.
crossref
36. Ruiz-del-Arbol L, Urman J, Fernández J, et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology. 2003; 38:1210–1218.
crossref
37. Tandon P, Garcia-Tsao G. Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol. 2011; 9:260–265.
crossref
38. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999; 341:403–409.
crossref
39. Sigal SH, Stanca CM, Fernandez J, Arroyo V, Navasa M. Restricted use of albumin for spontaneous bacterial peritonitis. Gut. 2007; 56:597–599.
crossref
40. Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology. 2008; 48:2064–2077.
crossref
41. Cárdenas A, Ginès P, Uriz J, et al. Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors, and short-term prognosis. Hepatology. 2001; 34(4 Pt 1):671–676.
crossref
42. Belcher JM, Garcia-Tsao G, Sanyal AJ, et al. Association of AKI with mortality and complications in hospitalized patients with cirrhosis. Hepatology. 2013; 57:753–762.
crossref
43. Warner NS, Cuthbert JA, Bhore R, Rockey DC. Acute kidney injury and chronic kidney disease in hospitalized patients with cirrhosis. J Investig Med. 2011; 59:1244–1251.
crossref
44. Wong F. Recent advances in our understanding of hepatorenal syndrome. Nat Rev Gastroenterol Hepatol. 2012; 9:382–391.
crossref
45. Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodés J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology. 1988; 8:1151–1157.
crossref
46. Ruiz-del-Arbol L, Monescillo A, Arocena C, et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology. 2005; 42:439–447.
crossref
47. Arroyo V, Colmenero J. Ascites and hepatorenal syndrome in cirrhosis: pathophysiological basis of therapy and current management. J Hepatol. 2003; 38:Suppl 1. S69–S89.
crossref
48. Schrier RW, Shchekochikhin D, Ginès P. Renal failure in cirrhosis: prerenal azotemia, hepatorenal syndrome and acute tubular necrosis. Nephrol Dial Transplant. 2012; 27:2625–2628.
crossref
49. Orlando R, Floreani M, Padrini R, Palatini P. Evaluation of measured and calculated creatinine clearances as glomerular filtration markers in different stages of liver cirrhosis. Clin Nephrol. 1999; 51:341–347.
50. Sherman DS, Fish DN, Teitelbaum I. Assessing renal function in cirrhotic patients: problems and pitfalls. Am J Kidney Dis. 2003; 41:269–278.
crossref
51. Caregaro L, Menon F, Angeli P, et al. Limitations of serum creatinine level and creatinine clearance as filtration markers in cirrhosis. Arch Intern Med. 1994; 154:201–205.
crossref
52. Spencer K. Analytical reviews in clinical biochemistry: the estimation of creatinine. Ann Clin Biochem. 1986; 23(Pt 1):1–25.
crossref
53. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the Acute Dialysis Quality Initiative (ADQI) group. Crit Care. 2004; 8:R204–R212.
54. Mehta RL, Kellum JA, Shah SV, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007; 11:R31.
crossref
55. Lassnigg A, Schmidlin D, Mouhieddine M, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol. 2004; 15:1597–1605.
crossref
56. Radhakrishnan J, Cattran DC. The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient. Kidney Int. 2012; 82:840–856.
crossref
57. Angeli P, Gatta A, Caregaro L, et al. Tubular site of renal sodium retention in ascitic liver cirrhosis evaluated by lithium clearance. Eur J Clin Invest. 1990; 20:111–117.
crossref
58. Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the international club of ascites. Gut. 2015; 64:531–537.
crossref
59. Salerno F, Gerbes A, Ginès P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007; 56:1310–1318.
crossref
60. Boyer TD, Sanyal AJ, Garcia-Tsao G, et al. Predictors of response to terlipressin plus albumin in hepatorenal syndrome (HRS) type 1: relationship of serum creatinine to hemodynamics. J Hepatol. 2011; 55:315–321.
crossref
61. Rodríguez E, Elia C, Solà E, et al. Terlipressin and albumin for type-1 hepatorenal syndrome associated with sepsis. J Hepatol. 2014; 60:955–961.
62. Tsien CD, Rabie R, Wong F. Acute kidney injury in decompensated cirrhosis. Gut. 2013; 62:131–137.
crossref
63. Salerno F, Navickis RJ, Wilkes MM. Albumin treatment regimen for type 1 hepatorenal syndrome: a dose-response meta-analysis. BMC Gastroenterol. 2015; 15:167.
crossref
64. Martín-Llahí M, Pépin MN, Guevara M, et al. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology. 2008; 134:1352–1359.
crossref
65. Sanyal AJ, Boyer T, Garcia-Tsao G, et al. A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology. 2008; 134:1360–1368.
crossref
66. Sanyal AJ, Boyer TD, Frederick RT, et al. Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs. placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studies. Aliment Pharmacol Ther. 2017; 45:1390–1402.
crossref
67. Cavallin M, Piano S, Romano A, et al. Terlipressin given by continuous intravenous infusion versus intravenous boluses in the treatment of hepatorenal syndrome: a randomized controlled study. Hepatology. 2016; 63:983–992.
crossref
68. Wong LP, Blackley MP, Andreoni KA, Chin H, Falk RJ, Klemmer PJ. Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Kidney Int. 2005; 68:362–370.
crossref
69. Gonwa TA, Klintmalm GB, Levy M, Jennings LS, Goldstein RM, Husberg BS. Impact of pretransplant renal function on survival after liver transplantation. Transplantation. 1995; 59:361–365.
crossref
70. Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology. 2002; 35:1179–1185.
crossref
71. Marik PE, Wood K, Starzl TE. The course of type 1 hepato-renal syndrome post liver transplantation. Nephrol Dial Transplant. 2006; 21:478–482.
crossref
72. Wong F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transpl. 2015; 21:300–307.
crossref
73. Nadim MK, Kellum JA, Davenport A, et al. Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) group. Crit Care. 2012; 16:R23.
crossref
74. Boyer TD, Sanyal AJ, Garcia-Tsao G, et al. Impact of liver transplantation on the survival of patients treated for hepatorenal syndrome type 1. Liver Transpl. 2011; 17:1328–1332.
crossref
TOOLS
ORCID iDs

Yeon Seok Seo
https://orcid.org/0000-0003-4171-6331

Similar articles