How would you workup a patient who develops ascites AFTER liver transplantation?

Evaluate ascites with triglyceride level to see if chylous - management of this is fat-restricted diet. This is common in the immediate post-transplant setting (1-3 months).

If ascites is high SAAG and low total protein, then a direct hepatic venogram with pressure measurements along the hepatic vein and IVC should be pursued to evaluate for hepatic vein stricture.

Challenging patient population. TTE to try to exclude cardiac etiology - HFpEF is often a significant factor, particularly with cardiorenal physiology. Sometimes, a hepatic venogram is needed to confirm no outflow obstruction. Good CTA to assess for portal vein stenosis - in the post-transplant setting, portal vein stenosis can result in ascites, where would not typically occur in the pre-transplant setting. Liver biopsy to evaluate for PSVD, changes that suggest small-for-size syndrome.