From the Guidelines
Diuretic management for liver cirrhosis patients after a TIPS procedure typically involves dose reduction or complete discontinuation of diuretics, with a focus on individualized management based on clinical response and close monitoring of fluid status, electrolyte levels, and renal function. Following TIPS placement, portal pressure decreases significantly, which often leads to improved sodium excretion and reduced ascites formation 1. Initially, diuretics (such as spironolactone and furosemide) should be reduced by approximately 50% immediately after the procedure, as guided by the American Association for the Study of Liver Diseases practice guidance 1. Patients should then be closely monitored for signs of fluid overload or dehydration, with regular weight monitoring and assessment of electrolyte levels (particularly sodium and potassium) and renal function.
Some key considerations in diuretic management post-TIPS include:
- Regular follow-up every 2-4 weeks initially to adjust diuretic dosing appropriately 1
- Individualized management based on clinical response, with consideration of pre-existing ascites or renal dysfunction 1
- Avoidance of overly aggressive diuresis, which can lead to dehydration, electrolyte abnormalities, and hepatic encephalopathy 1
- Consideration of albumin administration in certain cases, although the requirement for intravenous infusion limits standardized recommendation of albumin use 1
The management should prioritize minimizing adverse effects while maintaining adequate control of ascites, with the goal of improving patient outcomes in terms of morbidity, mortality, and quality of life. As noted in the 2021 practice guidance by the American Association for the Study of Liver Diseases, moderate sodium restriction and diuretics are the first-line treatment in patients with cirrhosis and grade 2 ascites, and attempts should be made to taper the diuretics to the lowest dose necessary to maintain minimal or no ascites 1.
From the Research
Diuretic Management for Liver Cirrhosis Patients after TIPs Procedure
- The medical treatment of ascites in cirrhosis is based on sodium restriction and the administration of diuretics 2, 3.
- Patients with cirrhosis and ascites must limit sodium intake to 2 gram per day, and enhancement of sodium excretion can be accomplished by usage of oral diuretics 2.
- The recommended initial dose is spironolactone 100-200 mg/d and furosemide 20-40 mg/d, with usual maximum doses being 400 mg/d of spironolactone and 160 mg/d of furosemide 2.
- About 90% of patients respond well to medical therapy for ascites, but refractory ascites is defined as fluid overload that is unresponsive to sodium restricted diet and high dose diuretic treatment 2.
- TIPS should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver functions 2.
- Ascites control by TIPS is more successful in patients with a lower paracentesis frequency and is associated with improved survival 4.
- Patients with persistent ascites post-TIPS had impaired transplant-free survival, for which persistent ascites was the only independent predictor 4.
Recommended Diuretics
- Spironolactone is the basic drug for the treatment of ascites, and the simultaneous administration of spironolactone and furosemide increases the natriuretic effect of each drug and diminishes their effects on potassium metabolism 3.
- Torasemide, in combination with spironolactone, has been shown to be effective in the treatment of cirrhotic ascites, with no untoward adverse reactions and no significant changes in serum electrolytes, liver, renal, or haematological variables 5.
- Loop diuretics, such as furosemide, can be used in combination with aldosterone antagonists, but their efficacy may be reduced due to hyperaldosteronism and impaired excretion into the tubular lumen 6.