What is the target mean arterial pressure (MAP) for patients with symptomatic ascites to ensure adequate renal perfusion and prevent hypotension?

From the Guidelines

The target mean arterial pressure (MAP) for patients with symptomatic ascites should be maintained at approximately 65 mmHg to ensure adequate renal perfusion and prevent hypotension. This recommendation is based on the most recent and highest quality study available, which suggests that maintaining an MAP of > 65 mmHg is associated with improved outcomes in critically ill patients with cirrhosis 1. The study found that ICU mortality increased below a threshold of 65 mmHg, highlighting the importance of maintaining adequate blood pressure in these patients.

To achieve this target, careful fluid management is essential, often requiring albumin infusions when needed for volume expansion rather than crystalloids alone. Vasopressors such as norepinephrine or midodrine may be necessary if fluid resuscitation alone is insufficient. It's also important to monitor renal function closely and avoid nephrotoxic medications. While some studies suggest that a higher MAP target may be beneficial, the most recent and highest quality evidence supports a target of 65 mmHg 1.

Some studies have suggested the use of midodrine in refractory ascites, which can help increase mean arterial pressure and urine sodium excretion 1. However, the primary goal should be to maintain an MAP of approximately 65 mmHg, and the use of midodrine or other vasopressors should be guided by this target. Overall, the key is to individualize the MAP target based on frequent assessment of end-organ perfusion and to use the most effective and safest strategies to achieve this target.

From the Research

Target Mean Arterial Pressure (MAP) for Patients with Symptomatic Ascites

The target mean arterial pressure (MAP) for patients with symptomatic ascites to ensure adequate renal perfusion and prevent hypotension is not explicitly stated in the provided studies. However, the studies suggest that a MAP of around 82 mmHg or higher may be beneficial for these patients.

• A study published in 2025 2 found that patients with diuretic intractable and recurrent ascites who received midodrine and weekly albumin therapy had a significant increase in MAP from 78.91±3.11 mmHg to 84.3±3.13 mmHg after three months of therapy.
• Another study published in 2022 3 found that the addition of midodrine resulted in a statistically significant improvement in MAP (MD, 3.95 mmHg; 95% CI, 1.53-6.36) compared to standard medical treatment.
• A study published in 2019 4 found that midodrine intake for 30 days improved renal perfusion significantly, but did not provide specific data on MAP.

Factors Affecting MAP in Patients with Symptomatic Ascites

Several factors can affect MAP in patients with symptomatic ascites, including:

• The use of vasoconstrictors such as midodrine 3, 2
• The use of albumin therapy 4, 2
• The presence of diuretic intractable and recurrent ascites 2
• The severity of liver disease, as measured by Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease-sodium (MELD-Na) scores 2

Clinical Implications

The clinical implications of these findings are that a target MAP of around 82 mmHg or higher may be beneficial for patients with symptomatic ascites, and that the use of midodrine and albumin therapy may help to achieve this target. However, further studies are needed to confirm these findings and to determine the optimal treatment strategy for these patients.