Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis

During the last decade great advances have been made concerning the pathogenesis and treatment of ascites, A new hypothesis on the mechanism of renal dysfunction and ascites formation in cirrhosis has been proposed and this has greatly stimulated research in this area, The discovery of the important role played by the vascular endothelium in the homeostasis of systemic hemodynamics and renal function has also opened an important field of research into pathophysiology, and evidence has been presented implicating endothelial factors in the pathogenesis of systemic circulatory dysfunction in cirrhosis and hepatorenal syndrome (HRS). The reintroduction of therapeutic paracentesis has greatly modified the treatment of cirrhotic patients with tense or refractory ascites. The transjugular intrahepatic portosystemic shunt is another therapeutic tool of potential interest in the management of refractory ascites. The synthesis of orally-active specific antagonists of the tubular effect of antidiuretic hormone and inhibitors of antidiuretic hormone release will probably add new drugs to the pharmacological armamentarium for patients with cirrhosis and ascites, These ''aquaretic drugs,'' which normalize renal water metabolism in experimental cirrhosis and ascites, are of potential interest for the treatment of water retention and dilutional hyponatremia in human cirrhosis. Finally, the field of spontaneous infection of ascitic fluid (spontaneous bacterial peritonitis) is also experiencing major changes. The demonstration of intestinal bacterial translocation in experimental models of cirrhosis, the potential role of cytokines in some complications associated with this infection, the identification of subgroups of cirrhotic patients predisposed to develop spontaneous bacterial peritonitis, and the effectiveness of selective intestinal decontamination in the primary and secondary prophylaxis of spontaneous bacterial peritonitis are the most relevant developments. In clear contrast to these advances, little attention has been paid to the standardization of the nomenclature and diagnostic criteria of different syndromes associated with ascites in cirrhosis, The existence of a uniform language, however, is essential in modern medicine, It facilitates communication among clinicians and researchers and ensures unambiguous diagnoses and more confident prognoses, Moreover, it improves pathophysiological and therapeutic investigations, simplifies the analysis of therapeutic trials, and stimulates multicenter studies.