What is the management approach for a patient with Hepatitis C (HCV), cirrhosis, and massive ascites?

From the Guidelines

For a patient with hepatitis C, cirrhosis, and massive ascites, the management approach should prioritize treatment of the underlying disease, with a focus on diuretics and large-volume paracentesis as needed, while also considering antiviral therapy for hepatitis C. The patient's treatment plan should include:

• Diuretics, with spironolactone as the primary diuretic, starting at 50-100 mg/day and increasing to 400 mg/day as needed, in combination with furosemide, starting at 20-40 mg/day and increasing to 160 mg/day 1
• Large-volume paracentesis, with albumin infusion of 6-8 g per liter of ascites drained 1
• Antiviral therapy for hepatitis C, with options including sofosbuvir and ribavirin for 12-16 weeks, or glecaprevir/pibrentasvir for 8-12 weeks 1
• Monitoring of liver function, kidney function, and electrolyte balance, with regular labs including:
  • Liver function tests (LFTs): ALT, AST, ALP, total bilirubin, albumin
  • Complete blood count (CBC)
  • Prothrombin time (PT) and INR
  • Basic metabolic panel (BMP)
  • Hepatitis C viral load and genotype (if not already known)
  • Alpha-fetoprotein (AFP) for hepatocellular carcinoma screening
  • Serum sodium and creatinine Additionally, consider:
• Diagnostic paracentesis of ascitic fluid for cell count, albumin, and culture
• Abdominal ultrasound to evaluate liver morphology and portal hypertension Regular monitoring of these parameters is crucial for managing complications and adjusting treatment as needed, with a focus on minimizing morbidity, mortality, and improving quality of life 1

From the FDA Drug Label

For patients with HCV/HIV-1 coinfection, follow the dosage recommendations in Table 1 [see Clinical Studies (14)] Genotype 1 or 4 infection who are liver transplant recipients without cirrhosis or with compensated cirrhosis, for use in combination with ribavirin Genotype 1 infection with decompensated cirrhosis, for use in combination with ribavirin The daily dosage of ribavirin is weight-based (1000 mg for patients <75 kg and 1200 mg for those ≥75 kg) administered orally in two divided doses with food. In patients with decompensated cirrhosis, the starting dosage of ribavirin is 600 mg and can be titrated up to 1000 mg for patients <75 kg and 1200 mg for those ≥75 kg in two divided doses with food

The management approach for a patient with Hepatitis C (HCV), cirrhosis, and massive ascites is to consider treatment with ledipasvir and sofosbuvir in combination with ribavirin.

• The treatment regimen and duration should be based on the patient's genotype and liver status.
• For patients with decompensated cirrhosis, the recommended treatment is ledipasvir and sofosbuvir + ribavirin for 12 weeks.
• The dosage of ribavirin should be weight-based and administered orally in two divided doses with food.
• Patients with massive ascites may require additional management, but the provided drug label does not directly address this condition 2.

From the Research

Management Approach for HCV, Cirrhosis, and Massive Ascites

The management of a patient with Hepatitis C (HCV), cirrhosis, and massive ascites involves a multi-step approach.

• Diagnosis of noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites is crucial since these occur with increased frequency in patients with liver disease 3.
• Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance 3, 4.
• Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy 3, 5.
• Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) 3, 4, 5.
• Prevention of complications such as spontaneous bacterial peritonitis and hepatorenal syndrome is essential, and antibiotic prophylaxis and albumin substitution may be necessary 6.
• Liver transplantation should be considered for all ascitic patients, preferably before the development of renal dysfunction 3, 4, 6.

Treatment Modalities

• Large-volume paracentesis is a safe, simple, and inexpensive method for the treatment of refractory, tense ascites 7, 5.
• TIPS placement can improve renal function, sodium excretion, and general well-being of the patient, but has no proven survival benefits 3.
• Diuretic therapy with spironolactone and loop-diuretics is effective in managing ascites, but potential complications and contraindications should be considered 3, 4.