The most appropriate next step in management is an evaluation for liver transplantation. This patient has decompensated cirrhosis as manifested by ascites and has a moderately elevated Model for End-Stage Liver Disease (MELD) score. The MELD score is an equation that incorporates the bilirubin, INR, and creatinine levels and was derived initially as a way to accurately predict 3-month and 1-year survival in patients undergoing a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The MELD score has also been validated as a tool for accurately predicting 3-month survival in patients with cirrhosis. This score is the basis for considering referral for liver transplantation (MELD ≥15) and organ allocation. Patients with cirrhotic-stage liver disease and a MELD score of 15 or greater have better survival with liver transplantation than without.

Diuretics have been unsuccessful in this patient owing to the development of kidney dysfunction. Further administration of diuretics may precipitate the development of hepatorenal syndrome; therefore, diuretics should be discontinued.

Patients with MELD scores greater than 10 are at risk of hepatic decompensation and mortality from any surgery, and especially with higher-risk surgeries such as a surgical portosystemic shunt. Therefore, surgical portosystemic shunt should not be performed in this patient, who has a MELD score of 21.

A TIPS can be an attractive option for patients whose ascites does not improve with medical management with a low-sodium diet (<2 g/d) and the usual diuretics (spironolactone and furosemide). However, a TIPS is contraindicated in patients with MELD scores greater than 15 to 18 or serum bilirubin levels greater than 4 mg/dL (68.4 µmol/L), owing to high risk of mortality.