EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis | 2010 EASL

Cirrose e Complicações 2010

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 successful treatment may improve 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.

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