The “Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases” is a comprehensive guidance on the diagnosis, evaluation, and management of the aforementioned complications of cirrhosis. It serves to replace the prior by the American Association for the Study of Liver Diseases (AASLD) guidelines on the same topics published in 2012. The Chronic Liver Disease Foundation (CLDF) is a nonprofit 501(c)(3) educational organization dedicated to raising awareness of liver disease. Members of the CLDF cirrhosis committee, actively involved in the management and treatment of patients with advanced liver disease, cirrhosis, and its complications, have provided their expert perspectives on this updated guidance. The result is this summary, which provides a streamlined version of the practical recommendations set forth in the guidance to facilitate their use in clinical practice.

Cirrhosis directly results in the development of splanchnic vasodilation, portal hypertension, and bacterial translocation. Specifically, splanchnic vasodilation leads to effective arterial underfilling associated with the activation of vasoconstrictor (e.g., renin-angiotensin) and antidiuretic (e.g., arginine vasopressin) factors. Both portal hypertension (because of increased sinusoidal) and bacterial translocation (because of gut permeability) contribute to the pathogenesis of complications associated with ascites, including hyponatremia, acute kidney injury, hepatorenal syndrome, and spontaneous bacterial infections.