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It is broadly based on the 2020 update of the Japanese clinical practice guidelines for liver cirrhosis, which is briefly compared with guidelines from Europe and the United States. Step 1 is sodium restriction at a level suitable for Japanese individuals (5\u20137\u00a0g\/day), Step 2 is albumin treatment to counteract underlying hypoalbuminemia, Step 3 is initiation of diuretic treatment with spironolactone, followed by add\u2010on loop diuretic treatment at Step 4. Patients that are refractory to sodium restriction and sodium diuretics can be treated with tolvaptan (Step 5) \u2013 a vasopressin V2 receptor antagonist that is available in Japan. Patients at Steps 6 and 7 have refractory ascites and are treated with large volume paracentesis in combination with an albumin infusion. High\u2010dose albumin infusion (6\u20138\u00a0g\/L) at the time of large volume paracentesis has recently become possible in Japan. Cell\u2010free and concentrated ascites reinfusion therapy is also an option at Step 6. Two of the treatment options at Step 7 are limited in Japan (transjugular intrahepatic portosystemic shunts are not approved, and access to liver donors is very limited), but patients can undergo a peritoneovenous shunt if no other options are available. While challenges remain in the treatment of ascites, adopting this stepwise treatment approach may improve patient outcomes.<\/jats:p>","DOI":"10.1111\/hepr.13937","type":"journal-article","created":{"date-parts":[[2023,6,19]],"date-time":"2023-06-19T04:14:45Z","timestamp":1687148085000},"page":"794-805","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Management of cirrhotic ascites: Seven\u2010step treatment protocol based on the Japanese evidence\u2010based clinical practice guidelines for liver cirrhosis 2020"],"prefix":"10.1111","volume":"53","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5243-8544","authenticated-orcid":false,"given":"Hitoshi","family":"Yoshiji","sequence":"first","affiliation":[{"name":"Department of Gastroenterology Nara Medical University  Kashihara Nara Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2023,7,25]]},"reference":[{"key":"e_1_2_8_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/S2468\u20101253(19)30349\u20108"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140\u20106736(21)01374\u2010X"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00535\u2010019\u201001645\u2010y"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.11405\/nisshoshi.114.8"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1504367"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1478\u20103231.2011.02517.x"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1002\/hep.1840070124"},{"key":"e_1_2_8_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/hepr.12769"},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1111\/hepr.13635"},{"key":"e_1_2_8_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2006.08.007"},{"key":"e_1_2_8_12_1","doi-asserted-by":"publisher","DOI":"10.1111\/hepr.13678"},{"key":"e_1_2_8_13_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00535\u2010021\u201001788\u2010x"},{"key":"e_1_2_8_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2018.03.024"},{"key":"e_1_2_8_15_1","doi-asserted-by":"publisher","DOI":"10.1002\/hep.31884"},{"key":"e_1_2_8_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.dld.2021.06.021"},{"key":"e_1_2_8_17_1","unstructured":"Japanese Society of Gastroenterology.Evidence\u2010based clinical practice guidelines for liver cirrhosis 2020.3rd ed;2020. 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