Liver failure

Ascites, SBP and hepatorenal syndrome in the ICU

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Diagnostic paracentesis in every admission, treat SBP with antibiotics plus albumin, safe large-volume paracentesis, and recognise HRS-AKI.

Definition
SBP = ascitic neutrophils (PMN) ≥ 250 cells/mm³ without a surgical source. HRS-AKI = AKI (ICA-KDIGO) in cirrhosis with ascites, not responding to 48 h diuretic withdrawal and albumin 1 g/kg, without shock, nephrotoxins or structural kidney disease.

At the bedside

  1. 1

    Diagnostic paracentesis

    In every cirrhotic admitted with ascites, GI bleed, encephalopathy, AKI or infection: cell count, culture in blood-culture bottles at bedside, albumin (SAAG), total protein. Coagulopathy is not a contraindication.

  2. 2

    Treat SBP

    Ceftriaxone 2 g/day or cefotaxime (community); piperacillin-tazobactam or carbapenem (nosocomial/MDR risk) for 5-7 days. Repeat tap at 48 h if not improving (PMN should fall ≥ 25%).

  3. 3

    Albumin in SBP

    1.5 g/kg on day 1 and 1 g/kg on day 3 (reduces AKI and death), especially if creatinine > 1 mg/dL, bilirubin > 4 mg/dL or urea high.

  4. 4

    Secondary bacterial peritonitis

    Suspect if PMN very high, multiple organisms, total protein > 1 g/dL, glucose < 50 mg/dL, LDH high: CT and surgical review.

  5. 5

    Large-volume paracentesis

    For tense ascites: drain; if > 5 L removed give albumin 6-8 g per litre removed (e.g. 8 L = 48-64 g). Safe without routine FFP/platelets.

  6. 6

    AKI in cirrhosis

    Stop diuretics, NSAIDs, nephrotoxins; treat infection; albumin 1 g/kg (max 100 g) for 2 days; if HRS-AKI criteria met, terlipressin + albumin (see AKI module).

  7. 7

    Prophylaxis

    Long-term norfloxacin/ciprofloxacin after SBP; avoid beta-blocker hypotension in refractory ascites (SBP < 90 mmHg, Na < 130, AKI).

SBP

Human albumin 20%

IV
Dose
1.5 g/kg day 1, 1 g/kg day 3
Worked example
70 kg: 105 g (5 × 100 mL of 20%) day 1, 70 g day 3

Watch for pulmonary oedema.

Large-volume paracentesis > 5 L

Human albumin 20%

IV
Dose
6-8 g per litre removed
Worked example
7 L drained: 42-56 g (2-3 × 100 mL of 20%)

Community-acquired SBP

Ceftriaxone

IV
Dose
2 g once daily for 5-7 days

Ascitic fluid interpretation

TestInterpretation
PMN ≥ 250/mm³SBP (treat empirically)
SAAG ≥ 1.1 g/dLPortal hypertension
SAAG < 1.1 g/dLNon-portal (TB, malignancy, pancreatic)
Protein > 1 g/dL + glucose < 50 mg/dL + LDH > serum ULNSecondary peritonitis (Runyon criteria)
ADA raised, lymphocytic, SAAG < 1.1Consider tuberculous peritonitis
Red flag · call your senior now
SBP with rising creatinine: high risk of HRS-AKI and death; give albumin and avoid nephrotoxins.
Pitfall
Waiting for culture before treating SBP; culture is negative in ~40% (culture-negative neutrocytic ascites is treated the same).
Pitfall
Giving FFP before paracentesis.
Pearl
Inoculating 10 mL of ascitic fluid into blood culture bottles at the bedside increases culture yield.

References

  1. 1

    Biggins SW, Angeli P, Garcia-Tsao G, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the AASLD. Hepatology 2021;74:1014-48.

  2. 2

    European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018;69:406-60.

  3. 3

    Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999;341:403-9.

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