Asia–Pacific association for study of liver guidelines on management of ascites in liver disease

The development of ascites is a landmark event in the natural history of cirrhosis. This guidance statement by the Asia–Pacific Association for Study of Liver (APASL) provides an evidence-based approach to managing ascites and its complications in patients with chronic liver disease. These guidelines extensively review the differential diagnosis, diagnostic evaluation, and management of ascites, hyponatremia, hepatic hydrothorax and hepatorenal syndrome (HRS) in patients with cirrhosis and acute-on-chronic liver failure (ACLF). A panel of international experts was invited to formulate the guidelines. The opinions of the experts were collected using two sets of Delphi questionnaires. Then, an online meeting of all the experts was held to discuss the evidence and formulate the final recommendations by consensus. The guidelines were developed using the GRADE system for analysing the level of evidence and strength of recommendation (Table 1). All authors have gone through the guidance document and endorse the same.In this document, we have also covered the grey areas which have been underexplored in previous guidelines and some of the issues which are relatively peculiar to the Asia–Pacific region. Given the high burden of tuberculosis in some of the countries of the Asia–Pacific region, mixed ascites is not uncommon in these patients with liver disease. We discuss the diagnostic approach to mixed ascites and the role of ascitic fluid adenosine deaminase (ADA) and other tests for tuberculosis. In addition, many countries in the Asia–Pacific region are low-middle-income countries, and financial constraints are an essential barrier to liver transplants and other costly therapies like albumin. Hence, we have discussed the role of low-dose albumin in the prevention of paracentesis-induced circulatory dysfunction (PICD) after large-volume paracentesis (LVP) and the prevention of acute kidney injury (AKI) in patients with spontaneous bacterial peritonitis (SBP). We have also reviewed the current evidence of outpatient albumin in managing patients with ascites and have made practical recommendations. We also highlight the timing of albumin infusion concerning LVP. To decrease adverse events and improve patient compliance with diuretic therapy, the guidelines emphasize initiating low-dose diuretics and gradually increasing the dose to the maximum tolerable dose. Non-alcoholic fatty liver disease (NAFLD), also referred to as Metabolic associated fatty liver disease (MAFLD) by some societies has become a significant cause of chronic liver disease worldwide [1]. Many patients with NAFLD/MAFLD related cirrhosis are on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) when they present to a hepatologist or gastroenterologist with ascites. For the first time, we provide guidance statements regarding the use of these drugs in patients with cirrhosis and ascites. For refractory ascites, we have now defined renal dysfunction following the International Club of Ascites (ICA) recommendations on AKI. Lastly, we have highlighted the gaps in our knowledge and have provided directions for future research