ASCITES AND HEPATORENAL-SYNDROME - PATHOPHYSIOLOGY AND MANAGEMENT

Ascites, a late manifestation of cirrhosis of the liver, causes increa sed morbidity and mortality, The renin-angiotensin-aldosterone system, the sympathetic nervous system, and arginine vasopressin are responsi ble for sodium and water retention in patients with cirrhosis, Fluid l ocalizes to the peritoneal cavity mainly as a result of portal hyperte nsion, Recent developments in the understanding of the pathophysiologi c mechanisms of ascites include the role of inadequate renal prostagla ndin production in the development of the hepatorenal syndrome and the possible role of nitric oxide in the pathogenesis of the renal compli cations of cirrhosis, The aim of medical therapy is to achieve a negat ive sodium balance and, consequently, fluid loss, Large-volume paracen tesis is safe and effective in the management of tense ascites, but us e of diuretic agents should be continued to prevent reaccumulation of ascites, Liver transplantation, transjugular intrahepatic portosystemi c shunts, or LeVeen shunts should be considered in selected patients w ith persistent ascites, In patients with diuretic-resistant or diureti c-refractory ascites, a thorough assessment must be performed to exclu de potentially reversible causes, The hepatorenal syndrome has an asso ciated grave prognosis, especially in patients who are not candidates for liver transplantation.