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Volume 5
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10.3390/livers5030046
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Review

Managing Ascites and Kidney Dysfunction in Decompensated Advanced Chronic Liver Disease: From “One Size Fits All” to a Multidisciplinary-Tailored Approach

by
Mario Romeo
1,
Carmine Napolitano
1,
Paolo Vaia
1,
Fiammetta Di Nardo
1,*,
Silvio Borrelli
2,
Carlo Garofalo
2,
Luca De Nicola
2,
Alessandro Federico
1 and
Marcello Dallio
1
1
Hepatogastroenterology Division, Department of Precision Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
2
Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
*
Author to whom correspondence should be addressed.
Livers 2025, 5(3), 46; https://doi.org/10.3390/livers5030046
Submission received: 11 August 2025 / Revised: 10 September 2025 / Accepted: 17 September 2025 / Published: 22 September 2025
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Abstract

Ascites and renal dysfunction are among the most frequent and severe complications of decompensated advanced chronic liver disease (dACLD), often representing two interrelated manifestations of a shared pathophysiological continuum. Recurrent ascites and refractory ascites pose significant therapeutic challenges and are frequently associated with kidney impairment, particularly hepatorenal syndrome. Recent advances have reshaped the understanding of the underlying mechanisms, moving beyond the classical paradigm of peripheral arterial vasodilation to encompass systemic inflammation, gut dysbiosis, and cirrhosis-associated immune dysfunction (CAID). These insights have prompted a shift from uniform treatment protocols toward personalized, multidisciplinary strategies. Therapeutic innovations such as long-term albumin infusion, a transjugular intrahepatic portosystemic shunt, and the Alfapump® system offer promising options, though each requires careful patient selection. Emerging approaches—including fecal microbiota transplantation and peritoneal dialysis—further expand the therapeutic landscape. Ultimately, early risk stratification, the integration of non-invasive tools, and individualized care models are essential to improving outcomes in this high-risk population. This review synthesizes current evidence and highlights future directions for the tailored management of dACLD patients with ascites and renal dysfunction.
Keywords: ascites; advanced chronic liver disease; interdisciplinary approach; evidence-based medicine; precision medicine ascites; advanced chronic liver disease; interdisciplinary approach; evidence-based medicine; precision medicine

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MDPI and ACS Style

Romeo, M.; Napolitano, C.; Vaia, P.; Di Nardo, F.; Borrelli, S.; Garofalo, C.; De Nicola, L.; Federico, A.; Dallio, M. Managing Ascites and Kidney Dysfunction in Decompensated Advanced Chronic Liver Disease: From “One Size Fits All” to a Multidisciplinary-Tailored Approach. Livers 2025, 5, 46. https://doi.org/10.3390/livers5030046

AMA Style

Romeo M, Napolitano C, Vaia P, Di Nardo F, Borrelli S, Garofalo C, De Nicola L, Federico A, Dallio M. Managing Ascites and Kidney Dysfunction in Decompensated Advanced Chronic Liver Disease: From “One Size Fits All” to a Multidisciplinary-Tailored Approach. Livers. 2025; 5(3):46. https://doi.org/10.3390/livers5030046

Chicago/Turabian Style

Romeo, Mario, Carmine Napolitano, Paolo Vaia, Fiammetta Di Nardo, Silvio Borrelli, Carlo Garofalo, Luca De Nicola, Alessandro Federico, and Marcello Dallio. 2025. "Managing Ascites and Kidney Dysfunction in Decompensated Advanced Chronic Liver Disease: From “One Size Fits All” to a Multidisciplinary-Tailored Approach" Livers 5, no. 3: 46. https://doi.org/10.3390/livers5030046

APA Style

Romeo, M., Napolitano, C., Vaia, P., Di Nardo, F., Borrelli, S., Garofalo, C., De Nicola, L., Federico, A., & Dallio, M. (2025). Managing Ascites and Kidney Dysfunction in Decompensated Advanced Chronic Liver Disease: From “One Size Fits All” to a Multidisciplinary-Tailored Approach. Livers, 5(3), 46. https://doi.org/10.3390/livers5030046

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