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Its pathogenesis is related to significant hemodynamic changes, initiated by portal hypertension, but ultimately leading to renal hypoperfusion and avid sodium retention. Inflammation can also contribute to the pathogenesis of refractory ascites by causing portal microthrombi, perpetuating the portal hypertension. Many complications accompany the development of refractory ascites, but renal dysfunction is most common. Management starts with continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesisinduced circulatory dysfunction. Albumin infusions independent of paracentesis may have a role in the management of these patients. The insertion of a covered, smaller diameter, transjugular intrahepatic porto-systemic stent shunt (TIPS) in the appropriate patients with reasonable liver reserve can bring about improvement in quality of life and improved survival after ascites clearance. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites should be referred for liver transplant, as their prognosis is poor. In patients with refractory ascites and concomitant chronic kidney disease of more than stage 3b, assessment should be referred for dual liver-kidney transplants. In patients with very advanced cirrhosis not suitable for any definitive treatment for ascites control, palliative care should be involved to improve the quality of life of these patients.<\/jats:p>","DOI":"10.3350\/cmh.2022.0104","type":"journal-article","created":{"date-parts":[[2022,6,9]],"date-time":"2022-06-09T05:33:05Z","timestamp":1654752785000},"page":"16-32","update-policy":"https:\/\/doi.org\/10.3350\/crossmark_policy","source":"Crossref","is-referenced-by-count":59,"title":["Management of refractory ascites"],"prefix":"10.3350","volume":"29","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9263-8869","authenticated-orcid":true,"given":"Florence","family":"Wong","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1902","reference":[{"key":"ref1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2036.2010.04473.x"},{"key":"ref2","doi-asserted-by":"publisher","DOI":"10.1111\/apt.15084"},{"key":"ref3","doi-asserted-by":"publisher","DOI":"10.1111\/j.1478-3231.2004.0991.x"},{"key":"ref4","doi-asserted-by":"publisher","DOI":"10.1111\/apt.15882"},{"key":"ref5","doi-asserted-by":"publisher","DOI":"10.1111\/j.1478-3231.2010.02272.x"},{"key":"ref6","doi-asserted-by":"publisher","DOI":"10.1038\/s41575-018-0097-3"},{"key":"ref7","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhepr.2021.100316"},{"key":"ref8","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2021.01.002"},{"key":"ref9","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2007.10.055"},{"key":"ref10","doi-asserted-by":"publisher","DOI":"10.1053\/jhep.2003.50315"},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1002\/hep.31884"},{"key":"ref12","doi-asserted-by":"publisher","DOI":"10.1038\/s41395-018-0185-6"},{"key":"ref13","first-page":"2417","volume-title":"Long-term albumin administration in decompensated cirrhosis (ANSWER): an open-label randomised trial","author":"Caraceni","year":"2018"},{"key":"ref14","first-page":"340","volume-title":"On-treatment serum albumin level can guide longterm treatment in patients with cirrhosis and uncomplicated ascites","author":"Caraceni","year":"2021"},{"key":"ref15","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2018.08.006"},{"key":"ref16","doi-asserted-by":"publisher","DOI":"10.1111\/liv.13968"},{"key":"ref17","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(18)31875-0"},{"key":"ref18","doi-asserted-by":"publisher","DOI":"10.1002\/hep.23775"},{"key":"ref19","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2011.01.034"},{"key":"ref20","doi-asserted-by":"publisher","DOI":"10.1002\/hep.28575"},{"key":"ref21","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2014.03.005"},{"key":"ref22","doi-asserted-by":"publisher","DOI":"10.1080\/00365521.2017.1329456"},{"key":"ref23","doi-asserted-by":"publisher","DOI":"10.1136\/gutjnl-2013-306502"},{"key":"ref24","first-page":"418","volume-title":"Non-selective beta-blocker use in cirrhotic patients is associated with a reduced likelihood of hospitalisation for infection","author":"Sasso","year":"2021"},{"key":"ref25","doi-asserted-by":"publisher","DOI":"10.1002\/hep.28352"},{"key":"ref26","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2015.10.018"},{"key":"ref27","doi-asserted-by":"publisher","DOI":"10.1111\/liv.15166"},{"key":"ref28","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2020.05.011"},{"key":"ref29","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2016.11.001"},{"key":"ref30","doi-asserted-by":"publisher","DOI":"10.1016\/0016-5085(87)91007-9"},{"key":"ref31","doi-asserted-by":"publisher","DOI":"10.1053\/gast.1997.v113.pm9247479"},{"key":"ref32","doi-asserted-by":"publisher","DOI":"10.1002\/hep.24786"},{"key":"ref33","doi-asserted-by":"publisher","DOI":"10.1016\/j.dld.2011.06.001"},{"key":"ref34","doi-asserted-by":"publisher","DOI":"10.1007\/s10620-016-4140-3"},{"key":"ref35","first-page":"394","volume-title":"Cardiovascular, renal, and neurohumoral responses to single large-volume paracentesis in patients with cirrhosis and diuretic-resistant ascites","author":"Peltekian","year":"1997"},{"key":"ref36","doi-asserted-by":"publisher","DOI":"10.1002\/hep.31071"},{"key":"ref37","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2009.05.004"},{"key":"ref38","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-122-11-199506010-00002"},{"key":"ref39","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2013.06.014"},{"key":"ref40","doi-asserted-by":"publisher","DOI":"10.1111\/jgh.12725"},{"key":"ref41","doi-asserted-by":"publisher","DOI":"10.1111\/j.1572-0241.2003.08664.x"},{"key":"ref42","first-page":"135","volume-title":"Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. 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