EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis European Association for the Study of the Liver

Ascites is the most common complication of cirrhosis, and 60% of patients with compensated cirrhosis develop ascites within 10 years during the course of their disease [1]. Ascites only occurs when portal hypertension has developed [2] and is primarily related to an inability to excrete an adequate amount of sodium into urine, leading to a positive sodium balance. A large body of evidence suggests that renal sodium retention in patients with cirrhosis is secondary to arterial splanchnic vasodilation. This causes a decrease in effective arterial blood volume with activation of arterial and cardiopulmonary volume receptors, and homeostatic activation of vasoconstrictor and sodium-retaining systems (i.e., the sympathetic nervous system and the renin-angiotensin-aldosterone system). Renal sodium retention leads to expansion of the extracellular fluid volume and formation of ascites and edema [3-5]. The development of ascites is associated with a poor prognosis and impaired quality of life in patients with cirrhosis [6,7]. Thus, patients with ascites should generally be considered for referral for liver transplantation. There is a clear rationale for the management of ascites in patients with cirrhosis, as a successful treatment may improve the outcome and symptoms. A panel of experts was selected by the EASL Governing Board and met several times to discuss and write these guidelines during 2008-2009. These guidelines were written according to published studies retrieved from Pubmed. The evidence and recommendations made in these guidelines have been graded according to the GRADE system (Grading of Recommendations Assessment Development and Evaluation). The strength of evidence has been classified into three levels: A, high; B, moderate; and C, low-quality evidence, while that of the recommendation into two: strong and weak (Table 1). Where no clear evidence existed, the recommendations were based on the consensus advice of expert opinion(s) in the literature and that of the writing committee.