Approach to persistent ascites after liver transplantation

Table 1 Overview of etiology, diagnosis, and treatment options for persistent ascites after liver transplantation

Etiology		Diagnosis	Treatment option1
Vascular	Hepatic outflow obstruction	Ultrasound of the abdomen with Doppler; Angiography and invasive hemodynamic evaluation	Balloon angioplasty +/- stent implantation; Surgical reconstruction
	Hepatic inflow obstruction
	Arterioportal fistulas
Hepatic	Acute cellular rejection	Evaluate liver function; Biopsy	Modify immunosuppressive therapy
	HCV recurrence	HCV serology; Biopsy	Antiviral drugs
Extrahepatic	Heart failure	NTproBNP; Echocardiogram	Treatment according to specialist recommendations
	Chronic kidney disease	Evaluate kidney function; Ultrasound
	Infection	Paracentesis; Determine site of the infection	Antibiotics
Unknown cause or refractory ascites		Preform all above mentioned diagnostic procedures	Transjugular intrahepatic portosystemic shuntSplenic artery embolization2

¹All patients should be treated with diuretics, antimineralocorticoid drugs or furosemide, in conjunction with a moderate restriction of sodium intake.

²Consider splenic artery embolization as the first treatment option when the initial spleen to liver volume ratio is > 0.5.

HCV: Hepatitis C virus; NTproBNP: N-terminal pro B-type natriuretic peptide.