[New therapeutic paradigm and concepts for patients with cirrhotic refractory ascites]

The activation of renin-angiotensin-aldosterone-vasopressin system is a key factor in the formation of ascites due to splanchnic vasodilation in cirrhosis. In theory, aldosterone antagonists, contraction of blood vessels, vasopressin V2 receptor, and angiotensin receptor antagonists are important targets for the prevention and treatment of cirrhotic ascites. The 15%-20% of patients with cirrhotic ascites that show no response to at least one week's treatment with potent diuretics (spironolactone 160 mg/d combined with furosemide 80 mg/d) are considered to have refractory ascites. At present, effective treatments for refractory ascites include tolvaptan, large-volume paracentesis (4000-6000 ml/time/day) combined with albumin (4 g/L ascites), ascites ultrafiltration and reinfusion, transjugular intrahepatic portosystemic shunt, and liver transplantation. In the future, with the development of vasoactive drugs, rifaximin, ascites drainage pump, and other new therapies, the treatment of refractory ascites may be more effective to reduce the need for liver transplantation.