Diagnosis and management of ascites and hepatorenal syndrome (acute kidney injury) in cirrhosis

The development of ascites and/or the hepatorenal syndrome in liver disease signifies the beginning of the end of liver function (decompensation). Patients with this condition need careful medical management to reverse these abnormalities, and identify any precipitating cause, such as spontaneous bacterial peritonitis or other causes of sepsis leading to acute kidney injury (AKI) or hepatorenal syndrome (HRS). Once ascites develops, all patients should be considered for liver transplantation because the long-term prognosis is poor. For those with alcoholic cirrhosis who stop drinking alcohol there is a large capacity for recovery. Likewise, treatment of newly presenting autoimmune hepatitis or chronic viral hepatitis (if tolerated) may improve liver function sufficiently to enable resolution of ascites without the need for diuretics. Patients should start a no-added-salt diet, and spironolactone as the first-line diuretic drug.The development of acute kidney injury or HRS is most commonly secondary to sepsis. Pathologically, HRS is due to a combination of vasodilatation causing a lowering of blood pressure, activation of the sympathetic nervous system, impairment of cardiac functional reserve, and increased synthesis of vasoactive mediators. Patients developing hepatorenal syndrome should be managed with volume expansion, terlipressin, and antibiotics.