EASL Clinical Practice Guidelines


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], [4], [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 a successful treatment may improve the 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.

Table 1
Grading evidence and recommendations (adapted from the GRADE system).

Notes Symbol
Grading of evidence
 High quality evidence Further research is very unlikely to change our confidence in the estimate of effect A
 Moderate quality evidence Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate B
 Low or very low quality of evidence Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Any estimate of effect is uncertain C
Grading recommendation
 Strong recommendation warranted Factors influencing the strength of the recommendation included the quality of evidence, presumed patient-important outcomes, and cost 1
 Weaker recommendation Variability in preferences and values, or more uncertainty: more likely a weak recommendation is warranted 2
Recommendation is made with less certainty: higher cost or resource consumption