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). These patients need careful medical management to reverse these abnormalities, and identify any precipitating cause such as sepsis or complication such as spontaneous bacterial peritonitis. Once ascites develops, all patients should be considered for liver transplantation since the long-term prognosis is poor. Patients should start modest salt restriction, and spironolactone as the first-line diuretic drug. Patients with alcoholic liver disease need to stop drinking.The development of hepatorenal syndrome is due to a combination of vasodilatation causing a lowering of blood pressure, activation of the sympathetic nervous system, impairment of cardiac function, and increased synthesis of vasoactive mediators. Patients developing hepatorenal syndrome should be managed with volume expansion, terlipressin, and a low threshold for intravenous antibiotics.