Ascites and HRS

SAAG = serum albumin − ascitic albumin, same day, rounded to 0.1 g/dL before classifying. 1.1 g/dL or more indicates portal hypertension (about 97% accuracy); under 1.1 points elsewhere — peritoneal carcinomatosis, tuberculous peritonitis and others (AASLD 2021).

Total protein above 2.5 g/dL with a high SAAG suggests a cardiac source (AASLD 2021). Below 1.5 g/dL is one criterion for primary SBP prophylaxis, with creatinine above 1.2 mg/dL, BUN above 25 mg/dL or sodium below 130 mmol/L, or Child-Pugh above 9 with bilirubin above 3 mg/dL.

SBP: PMN above 250/mm³ without a surgical source. PMN 250 or less with a positive culture and no signs of infection is bacterascites: no antibiotics, repeat the tap (AASLD 2021).

LVP albumin: more than 5 L removed → 6–8 g per liter removed (AASLD 2021; AGA 2025 "per every total liter"; AASLD worked example ≈64 g after 8 L). The tool counts every liter. ICA-ADQI 2024 says 6–8 g “for every litre over 5 L”, which can be read either way — follow your protocol. Above 8 L in one session, the risk of post-paracentesis circulatory dysfunction may rise. Volume of 25% albumin = grams × 4 mL.

SBP albumin: 1.5 g/kg on day 1 and 1 g/kg on day 3 (Sort 1999; AASLD 2021), using actual body weight as in the trial. No guideline sets a maximum; the tool flags doses above 100 g for a volume-status check. ICA-ADQI 2024 advises letting haemodynamics and volume status guide the dose.

All four: (a) cirrhosis with ascites; (b) creatinine rise ≥0.3 mg/dL (26.5 µmol/L) within 48 h or ≥50% from baseline known or presumed within 7 days, and/or urine output ≤0.5 mL/kg/h for ≥6 h; (c) no improvement in creatinine and/or urine output within 24 h of adequate volume resuscitation when clinically indicated; (d) no strong evidence for an alternative primary cause.

In mg/dL the rise is rounded to 0.01 mg/dL. In µmol/L the rise is taken directly from the entered values and rounded to a whole number; 26.5 µmol/L or more (27 or more as shown) meets the absolute criterion. Percent is rounded to the whole number before classifying.

Baseline: lowest stable value in the prior 3 months; else the most recent up to 12 months; with none, the lower of admission creatinine and the value back-calculated from eGFR 75 mL/min/1.73 m² (not computed here).

Changes from older criteria: the fixed 1.5 mg/dL threshold was dropped by the ICA in 2015. 2024 added urine output, removed the mandatory 48 h albumin (still in AASLD 2021, Table 11: 1 g/kg/day × 2 days, maximum 100 g/day per ICA 2015), and accepts coexisting CKD, proteinuria or tubular injury.

Contraindicated: hypoxia or worsening respiratory symptoms; ongoing coronary, peripheral or mesenteric ischemia. Do not initiate with SpO₂ under 90%; monitor continuously and stop if it falls under 90%.

Avoid: ACLF grade 3; history of severe cardiovascular, cerebrovascular or ischemic disease. Increased risk: volume overload — reduce or stop albumin and fluids, use diuretics judiciously, and interrupt or reduce terlipressin until volume improves (the tool withholds the starting dose while overload is present). Weigh: MELD ≥35; pregnancy (fetal harm). Limitation of use: creatinine above 5 mg/dL is unlikely to benefit.

Dose: 0.85 mg IV bolus over 2 min every 6 h, days 1–3. Day 4 versus baseline: decrease ≥30% → continue 0.85 mg; decrease under 30% → may increase to 1.7 mg every 6 h (top dose in the label’s dosing chart, 6.8 mg/day); at or above baseline (compared on the entered values) → discontinue. The 30% cut uses the percent shown, rounded to 0.1%. SpO₂ is gated on the value as entered (89.6% counts as under 90%). Continue until 24 h after two consecutive creatinine values ≤1.5 mg/dL at least 2 h apart, or 14 days maximum.

ICA-ADQI 2024 escalates every 24 h if creatinine has not fallen 25%, and many centres outside the US give continuous infusions; neither is the US label.