Thirst in End-Stage Liver Disease: From Symptom Disregard to a Multidisciplinary Clinical Pathway and Future Perspectives: A Narrative Review.

Purpose: Thirst is a common but clinically under-recognized symptom among patients with end-stage liver disease (ESLD) and may adversely affect comfort, nutritional intake, treatment adherence, and quality of life. This review aimed to systematically elucidate the pathogenesis, clinical management dilemmas, and limitations of current interventions, while highlighting the need for population-specific assessment tools and an integrated management framework. Methods: A narrative review was based on a structured literature search of PubMed, Web of Science, CINAHL, and Scopus from database inception through December 2025. Original studies, reviews, and clinical guidelines addressing thirst, dry mouth, symptoms, and fluid management in ESLD were included, and the evidence was synthesized thematically. Results: Thirst in ESLD results from interactions among liver failure, portal hypertension, diuretic and vasopressin V2 receptor antagonist use, electrolyte disturbances, and salivary dysfunction. Four major clinical dilemmas were identified: (i) Fluid restriction for ascites may aggravate thirst; (ii) diuretics are essential for controlling ascites but may intensify symptoms; (iii) hyponatremia management requires careful fluid regulation despite thirst aggravated by reduced effective arterial blood volume, neurohumoral activation, diuretic exposure, oral dryness, and fluid restriction; (iv) hepatogenous diabetes and salivary dysfunction may further contribute to persistent dry mouth and thirst. Current assessment strategies rely on non-specific tools including the Numerical Rating Scale (NRS) and Thirst Distress Scale (TDS), because no ESLD-specific instrument exists. Non-pharmacological interventions, such as ice-cold water spray and mint ice cubes, are promising but require validation in ESLD-specific clinical trials. Conclusion: Thirst in ESLD is a multifactorial and distressing symptom that remains inadequately managed. We propose a "4S" integrated management framework (Screening, Scoring, Stratification, and Stepped care) to guide clinical practice. Future research should prioritize mechanism-driven human studies, randomized controlled trials evaluating targeted interventions, and the development of an ESLD-specific thirst assessment scale.