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

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

Purpose and Scope of the Guidance

This is a comprehensive guidance on the diagnosis, evaluation, and management of ascites and hepatorenal syndrome (HRS) 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 (Table 1).⁽¹⁾

TABLE 1. What’s New in This Guidance

Because this guidance represents an update covering nearly a decade, numerous changes are made. Instead of enumerating the individual changes, the following list represents noticeable revisions:

Table 3 includes specific directions on the diagnostic evaluation of ascites by clinical setting and clinical course.
Tables 5 and 7 highlight specific definitions and characteristic of ascites.
Figure 3 provides updated information on management of ascites, including the use of albumin in ascites.
More specific definitions of hyponatremia and management are included.
Updated guidance on LT for patients with HH (Table 8) and for potential candidates of simultaneous liver-kidney transplantation
Table 9 has expanded and updated description of antibiotics for infections in patients with cirrhosis.
The AKI section is substantially expanded and updated (Fig. 4; Tables 10-12).
The pediatric section is new.

This AASLD Guidance provides a data-supported approach to the management of ascites and HRS. It differs from the 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.