2017 Korean Association for the Study of the Liver (KASL) Clinical Practice Guidelines for Ascites and Related Complications: What Has Been Changed from the 2011 KASL Clinical Practice Guidelines?

2017년 대한간학회 복수 및 관련 합병증 진료 가이드라인 소개: 2011년 가이드라인과 어떻게 달라졌는가?

  • Seo, Yeon Seok (Department of Internal Medicine, Korea University College of Medicine)
  • 서연석 (고려대학교 의과대학 내과학교실)
  • Received : 2018.09.19
  • Accepted : 2018.09.28
  • Published : 2018.10.31


Ascites is a common complication in patients with liver cirrhosis and is the most common cause of hospitalization in these patients. The development of ascites is associated with a poor prognosis in patients with liver cirrhosis with a higher mortality rate than in those without ascites. Furthermore, the presence of cirrhotic ascites is related to the development of various serious complications, such as refractory ascites, spontaneous bacterial peritonitis, acute kidney injury, and hepatorenal syndrome. Therefore, early detection and appropriate management for the development of ascites and their complications is very important in these patients. Recently, there have been significant revisions in the diagnostic criteria and treatment of cirrhotic ascites and their complications. This manuscript reviews these revisions.


  1. Gines P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology 1987;7:122-128.
  2. Lucena MI, Andrade RJ, Tognoni G, et al. Multicenter hospital study on prescribing patterns for prophylaxis and treatment of complications of cirrhosis. Eur J Clin Pharmacol 2002;58:435-440.
  3. Planas R, Montoliu S, Balleste B, et al. Natural history of patients hospitalized for management of cirrhotic ascites. Clin Gastroenterol Hepatol 2006;4:1385-1394.
  4. Suk KT, Baik SK, Yoon JH, et al. Revision and update on clinical practice guideline for liver cirrhosis. Korean J Hepatol 2012;18:1-21.
  5. Korean Association for the Study of the Liver. KASL clinical practice guidelines for liver cirrhosis: ascites and related complications. Clin Mol Hepatol 2018;24:230-277.
  6. Kuiper JJ, de Man RA, van Buuren HR. Review article: management of ascites and associated complications in patients with cirrhosis. Aliment Pharmacol Ther 2007;26 Suppl 2:183-193.
  7. Runyon BA. Care of patients with ascites. N Engl J Med 1994;330:337-342.
  8. Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Dig Liver Dis 2001;33:41-48.
  9. Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992;117:215-220.
  10. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006;55 Suppl 6:vi1-12.
  11. Santos J, Planas R, Pardo A, et al. Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A randomized comparative study of efficacy and safety. J Hepatol 2003;39:187-192.
  12. Angeli P, Dalla Pria M, De Bei E, et al. Randomized clinical study of the efficacy of amiloride and potassium canrenoate in nonazotemic cirrhotic patients with ascites. Hepatology 1994;19:72-79.
  13. Arroyo V, Gines P, Gerbes AL, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International ascites club. Hepatology 1996;23:164-176.
  14. Rossle M, Ochs A, Gulberg V, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000;342:1701-1707.
  15. Azoulay D, Castaing D, Dennison A, Martino W, Eyraud D, Bismuth H. Transjugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: preliminary report of a prospective study. Hepatology 1994;19:129-132.
  16. Michl P, Gulberg V, Bilzer M, Waggershauser T, Reiser M, Gerbes AL. Transjugular intrahepatic portosystemic shunt for cirrhosis and ascites: effects in patients with organic or functional renal failure. Scand J Gastroenterol 2000;35:654-658.
  17. Seo JH, Kim SU, Park JY, et al. Predictors of refractory ascites development in patients with hepatitis B virus-related cirrhosis hospitalized to control ascitic decompensation. Yonsei Med J 2013;54:145-153.
  18. Heuman DM, Abou-Assi SG, Habib A, et al. Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death. Hepatology 2004;40:802-810.
  19. Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol 1993;18:353-358.
  20. Tandon P, Garcia-Tsao G. Bacterial infections, sepsis, and multiorgan failure in cirrhosis. Semin Liver Dis 2008;28:26-42.
  21. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53:397-417.
  22. Runyon BA. Monomicrobial nonneutrocytic bacterascites: a variant of spontaneous bacterial peritonitis. Hepatology 1990;12(4 Pt 1):710-715.
  23. Soriano G, Castellote J, Alvarez C, et al. Secondary bacterial peritonitis in cirrhosis: a retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol 2010;52:39-44.
  24. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990;98:127-133.
  25. Runyon BA, Hoefs JC. Ascitic fluid analysis in the differentiation of spontaneous bacterial peritonitis from gastrointestinal tract perforation into ascitic fluid. Hepatology 1984;4:447-450.
  26. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 2007;132:1261-1269.
  27. Wu SS, Lin OS, Chen YY, Hwang KL, Soon MS, Keeffe EB. Ascitic fluid carcinoembryonic antigen and alkaline phosphatase levels for the differentiation of primary from secondary bacterial peritonitis with intestinal perforation. J Hepatol 2001;34:215-221.
  28. Rimola A, Garcia-Tsao G, Navasa M, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International ascites club. J Hepatol 2000;32:142-153.
  29. Piano S, Fasolato S, Salinas F, et al. The empirical antibiotic treatment of nosocomial spontaneous bacterial peritonitis: results of a randomized, controlled clinical trial. Hepatology 2016;63:1299-1309.
  30. Fernandez J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55:1551-1561.
  31. Cheong HS, Kang CI, Lee JA, et al. Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis. Clin Infect Dis 2009;48:1230-1236.
  32. Fernandez J, Tandon P, Mensa J, Garcia-Tsao G. Antibiotic prophylaxis in cirrhosis: good and bad. Hepatology 2016;63:2019-2031.
  33. Jalan R, Fernandez J, Wiest R, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014;60:1310-1324.
  34. Wiest R, Krag A, Gerbes A. Spontaneous bacterial peritonitis: recent guidelines and beyond. Gut 2012;61:297-310.
  35. Follo A, Llovet JM, Navasa M, et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology 1994;20:1495-1501.
  36. Ruiz-del-Arbol L, Urman J, Fernandez J, et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology 2003;38:1210-1218.
  37. Tandon P, Garcia-Tsao G. Renal dysfunction is the most important independent predictor of mortality in cirrhotic patients with spontaneous bacterial peritonitis. Clin Gastroenterol Hepatol 2011;9:260-265.
  38. Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403-409.
  39. Sigal SH, Stanca CM, Fernandez J, Arroyo V, Navasa M. Restricted use of albumin for spontaneous bacterial peritonitis. Gut 2007;56:597-599.
  40. Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology 2008;48:2064-2077.
  41. Cardenas A, Gines P, Uriz J, et al. Renal failure after upper gastrointestinal bleeding in cirrhosis: incidence, clinical course, predictive factors, and short-term prognosis. Hepatology 2001;34(4 Pt 1):671-676.
  42. Belcher JM, Garcia-Tsao G, Sanyal AJ, et al. Association of AKI with mortality and complications in hospitalized patients with cirrhosis. Hepatology 2013;57:753-762.
  43. Warner NS, Cuthbert JA, Bhore R, Rockey DC. Acute kidney injury and chronic kidney disease in hospitalized patients with cirrhosis. J Investig Med 2011;59:1244-1251.
  44. Wong F. Recent advances in our understanding of hepatorenal syndrome. Nat Rev Gastroenterol Hepatol 2012;9:382-391.
  45. Schrier RW, Arroyo V, Bernardi M, Epstein M, Henriksen JH, Rodes J. Peripheral arterial vasodilation hypothesis: a proposal for the initiation of renal sodium and water retention in cirrhosis. Hepatology 1988;8:1151-1157.
  46. Ruiz-del-Arbol L, Monescillo A, Arocena C, et al. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology 2005;42:439-447.
  47. Arroyo V, Colmenero J. Ascites and hepatorenal syndrome in cirrhosis: pathophysiological basis of therapy and current management. J Hepatol 2003;38 Suppl 1:S69-S89.
  48. Schrier RW, Shchekochikhin D, Gines P. Renal failure in cirrhosis: prerenal azotemia, hepatorenal syndrome and acute tubular necrosis. Nephrol Dial Transplant 2012;27:2625-2628.
  49. Orlando R, Floreani M, Padrini R, Palatini P. Evaluation of measured and calculated creatinine clearances as glomerular filtration markers in different stages of liver cirrhosis. Clin Nephrol 1999;51:341-347.
  50. Sherman DS, Fish DN, Teitelbaum I. Assessing renal function in cirrhotic patients: problems and pitfalls. Am J Kidney Dis 2003;41:269-278.
  51. Caregaro L, Menon F, Angeli P, et al. Limitations of serum creatinine level and creatinine clearance as filtration markers in cirrhosis. Arch Intern Med 1994;154:201-205.
  52. Spencer K. Analytical reviews in clinical biochemistry: the estimation of creatinine. Ann Clin Biochem 1986;23 (Pt 1):1-25.
  53. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the Acute Dialysis Quality Initiative (ADQI) group. Crit Care 2004;8:R204-R212.
  54. Mehta RL, Kellum JA, Shah SV, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.
  55. Lassnigg A, Schmidlin D, Mouhieddine M, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 2004;15:1597-1605.
  56. Radhakrishnan J, Cattran DC. The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient. Kidney Int 2012;82:840-856.
  57. Angeli P, Gatta A, Caregaro L, et al. Tubular site of renal sodium retention in ascitic liver cirrhosis evaluated by lithium clearance. Eur J Clin Invest 1990;20:111-117.
  58. Angeli P, Gines P, Wong F, et al. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the international club of ascites. Gut 2015;64:531-537.
  59. Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut 2007;56:1310-1318.
  60. Boyer TD, Sanyal AJ, Garcia-Tsao G, et al. Predictors of response to terlipressin plus albumin in hepatorenal syndrome (HRS) type 1: relationship of serum creatinine to hemodynamics. J Hepatol 2011;55:315-321.
  61. Rodriguez E, Elia C, Sola E, et al. Terlipressin and albumin for type-1 hepatorenal syndrome associated with sepsis. J Hepatol 2014;60:955-961.
  62. Tsien CD, Rabie R, Wong F. Acute kidney injury in decompensated cirrhosis. Gut 2013;62:131-137.
  63. Salerno F, Navickis RJ, Wilkes MM. Albumin treatment regimen for type 1 hepatorenal syndrome: a dose-response meta-analysis. BMC Gastroenterol 2015;15:167.
  64. Martin-Llahi M, Pepin MN, Guevara M, et al. Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology 2008;134:1352-1359.
  65. Sanyal AJ, Boyer T, Garcia-Tsao G, et al. A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology 2008;134:1360-1368.
  66. Sanyal AJ, Boyer TD, Frederick RT, et al. Reversal of hepatorenal syndrome type 1 with terlipressin plus albumin vs. placebo plus albumin in a pooled analysis of the OT-0401 and REVERSE randomised clinical studies. Aliment Pharmacol Ther 2017;45:1390-1402.
  67. Cavallin M, Piano S, Romano A, et al. Terlipressin given by continuous intravenous infusion versus intravenous boluses in the treatment of hepatorenal syndrome: a randomized controlled study. Hepatology 2016;63:983-992.
  68. Wong LP, Blackley MP, Andreoni KA, Chin H, Falk RJ, Klemmer PJ. Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Kidney Int 2005;68:362-370.
  69. Gonwa TA, Klintmalm GB, Levy M, Jennings LS, Goldstein RM, Husberg BS. Impact of pretransplant renal function on survival after liver transplantation. Transplantation 1995;59:361-365.
  70. Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology 2002;35:1179-1185.
  71. Marik PE, Wood K, Starzl TE. The course of type 1 hepato-renal syndrome post liver transplantation. Nephrol Dial Transplant 2006;21:478-482.
  72. Wong F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transpl 2015;21:300-307.
  73. Nadim MK, Kellum JA, Davenport A, et al. Hepatorenal syndrome: the 8th international consensus conference of the Acute Dialysis Quality Initiative (ADQI) group. Crit Care 2012;16:R23.
  74. Boyer TD, Sanyal AJ, Garcia-Tsao G, et al. Impact of liver transplantation on the survival of patients treated for hepatorenal syndrome type 1. Liver Transpl 2011;17:1328-1332.