Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases

Abstract

This is a comprehensive guidance on the diagnosis, evaluation, and management of ascites and hepatorenal syndrome in patients with chronic liver disease from the American Association for the Study of Liver Diseases (AASLD). It replaces the prior AASLD guideline on the same topic published in 2012 (1).This AASLD Guidance provides a data-supported approach to the management of ascites and hepatorenal syndrome. It differs from AASLD Guidelines, which are supported by systematic reviews of the literature, formal rating of the quality of the evidence and strength of the recommendations. In contrast, this Guidance was developed by consensus of an expert panel and provides guidance statements based on comprehensive review and analysis of the literature on the topics, with oversight provided by the AASLD Practice Guidelines Committee. The AASLD Practice Guidelines Committee chose to perform a Guidance on this topic because a sufficient number of randomized controlled trials were not available to support meaningful systematic reviews and meta-analyses. A. Introduction Burden of Cirrhotic Ascites and Hepatorenal SyndromeHepatic decompensation, defined by ascites, hepatic encephalopathy, and portal hypertensive gastrointestinal bleeding, is an important landmark in the natural history of cirrhosis (2). Ascites is commonly the first decompensation-defining event, with 5%-10% of patients with compensated cirrhosis developing ascites per year (3). The development of ascites is associated with a reduction in 5-year survival from 80% to 30% (4), which is due in part to patients with ascites being prone to additional complications such as bacterial infections, electrolyte abnormalities, hepatorenal syndrome (HRS) and nutritional imbalances, and consequently, further clinical decline (5). Patients with cirrhosis who develop clinically significant ascites and related complications should be considered for referral for liver transplantation (LT) evaluation and, where appropriate, palliative care (6).HRS is a late complication of cirrhosis that accounted for 3.2% of all hospital discharges related to cirrhosis according to a 2012 study based on a large inpatient health care database of patients representative of community hospitals in the United States (4). Moreover, the number of HRS discharges in the United States has increased significantly in the past 2 decades (7). HRS was also associated with high inpatient mortality (~46%), as well as longer lengths of stay and higher costs of hospitalizations, compared to cirrhosis discharges without HRS.

Einsatz von Albumin

“…In der "Human-albumin-for-thetreatment-of-ascites-in-patients-with-hepatic-cirrhosis"(ANSWER)-Studie führte eine wöchentliche HA-Gabe zur Reduktion von Mortalität und Komplikationen [11]. Eine allgemeine Empfehlung für die Langzeitgabe von HA existiert im Moment aber noch nicht [8]. In 2 anderen Studien, "midodrine and albumin for prevention of complications in patients with cirrhosis awaiting liver transplantation" (MACHT) und "a randomized trial of albumin infusions in hospitalized patients with cirrhosis" (ATTIRE), die jedoch in Bezug auf Studiendesign und HA-Gabe nur bedingt vergleichbar sind, konnte ein Vorteil wie in ANSWER nicht nachgewiesen werden [14,54].…”

The Role of Urinary N-Acetyl-β-d-glucosaminidase in Cirrhotic Patients with Acute Kidney Injury: Multicenter, Prospective Cohort Study

“…Occurring in 40-50% of hospitalized patients, acute kidney injury (AKI) is a common complication in patients with advanced liver cirrhosis [1,2]. Numerous studies have established that kidney function plays a major role in the prognosis of cirrhosis [3].…”

Prophylactic Perioperative Terlipressin Therapy for Preventing Acute Kidney Injury in Living Donor Liver Transplant Recipients: A Systematic Review and Meta-Analysis

“…4 Terlipressin (Tp) is the recommended standard of care for acute variceal bleed and HRS. [5][6][7] The role of Tp has also been evaluated in multiple other conditions, such as preventing paracentesis-induced circulatory dysfunction, refractory ascites, septic shock, and perioperatively during hepatobiliary surgery and liver transplantation but with limited success. 7 Tp reduces portal blood flow and portal pressure and increases systemic vascular resistance (SVR) and renal perfusion.…”