EASL 2018 decompensated cirrhosis guidelines: key recommendations

Who it applies to

Adults with cirrhosis who develop decompensating events such as ascites, infection, or renal dysfunction, managed in outpatient or inpatient hospital settings.

Key recommendations

• First-line management of uncomplicated ascites is sodium restriction combined with diuretics, typically starting with aldosterone antagonists and adding loop diuretics as needed.
• Large-volume paracentesis for tense ascites should be accompanied by albumin infusion to reduce the risk of paracentesis-induced circulatory dysfunction.
• Spontaneous bacterial peritonitis should be diagnosed by ascitic fluid neutrophil count and treated promptly with empirical antibiotics, with albumin given in those with renal impairment or high bilirubin to reduce mortality.
• Hepatorenal syndrome-acute kidney injury should be treated with vasoconstrictors, preferably terlipressin, together with albumin, aiming for reversal of renal failure.
• Hyponatremia should be managed according to severity and symptoms, with fluid restriction as a mainstay and cautious correction to avoid overly rapid rises in sodium.
• Patients with cirrhosis and acute kidney injury should have nephrotoxic drugs and diuretics withdrawn and volume status optimized before diagnosing hepatorenal syndrome.
• Long-term norfloxacin prophylaxis is recommended in selected high-risk patients, including those with prior spontaneous bacterial peritonitis or low ascitic protein with advanced liver or renal dysfunction.
• Non-selective beta-blockers are useful in the prevention of variceal bleeding but require caution or dose adjustment in refractory ascites or circulatory compromise.
• Acute-on-chronic liver failure is recognized as a distinct syndrome characterized by organ failures and high short-term mortality, warranting consideration of intensive care and early transplant evaluation.
• Nutritional assessment and support are recommended for all patients with decompensated cirrhosis given the high prevalence of malnutrition and sarcopenia affecting prognosis.

What is new in this edition

• Formal incorporation of acute-on-chronic liver failure as a defined clinical entity with its own diagnostic framework
• Expanded guidance on albumin use beyond paracentesis, including in spontaneous bacterial peritonitis and selected renal impairment scenarios
• Greater emphasis on individualized, staged definitions of acute kidney injury in cirrhosis rather than fixed creatinine thresholds alone
• Reclassification of hepatorenal syndrome type 1 as a form of acute kidney injury (hepatorenal syndrome-acute kidney injury) under the updated staging system

Practice points for students

• Always send ascitic fluid for neutrophil count and culture before starting antibiotics when spontaneous bacterial peritonitis is suspected.
• Albumin plus terlipressin is the standard first-line pharmacological approach to hepatorenal syndrome-acute kidney injury.
• Stop diuretics and nephrotoxic agents early when acute kidney injury develops in a cirrhotic patient.
• Hyponatremia correction should be gradual; rapid correction risks neurological complications.
• Decompensated cirrhosis should prompt early consideration of liver transplant referral given its prognostic implications.

Condition

Other guidelines on this topic

• ACG Clinical Guideline: Preventive Care for Patients With CirrhosisACG2026Official guideline
• AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosisAASLD2024Summary
• Cirrhosis in over 16s: assessment and management (NG50)NICE2023Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by EASL. It is not medical advice: always read the original guideline before applying it to patients.