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Serum-ascites albumin gradient – A false dichotomy in the approach to ascites

Published:April 15, 2022DOI:https://doi.org/10.1016/j.ejim.2022.04.010
      Ascites is a clinical scenario frequently encountered in primary care, internal medicine and gastroenterology. Formal guidelines on its approach and management exist and recommend measuring the serum-ascites albumin gradient (SAAG) as part of the routine evaluation of new-onset ascites to guide the clinician in determining the underlying etiology [
      • Kim W.R.
      • Biggins S.W.
      • Angeli P.
      • et al.
      Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome : 2021 practice guidance by the American association for the study of liver diseases.
      ,
      • Aithal G.P.
      • Palaniyappan N.
      • Härmälä S.
      • et al.
      Guidelines on the management of ascites in cirrhosis.
      ]. SAAG is in reality a discrete numerical variable that was dichotomized in early studies from which ascites guidelines support their recommendations [
      • Runyon B.A.
      • Montano A.A.
      • Akriviadis E.A.
      • Antillon M.R.
      • Irving M.A.
      • Mchutchison J.G.
      The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites.
      ,
      • Sampliner R.E.
      • Iber F.L.
      High protein ascites in patients with uncomplicated hepatic cirrhosis.
      ]. For example, a threshold of ≥1.1 g/dL for SAAG indicates portal hypertension as the likely cause of ascites [
      • Kim W.R.
      • Biggins S.W.
      • Angeli P.
      • et al.
      Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome : 2021 practice guidance by the American association for the study of liver diseases.
      ,
      • Aithal G.P.
      • Palaniyappan N.
      • Härmälä S.
      • et al.
      Guidelines on the management of ascites in cirrhosis.
      ].

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