What is the treatment for worsening ascites in liver cirrhosis?

From the Guidelines

The treatment for worsening ascites in liver cirrhosis involves a stepwise approach starting with sodium restriction and diuretics, with the most recent guidelines recommending spironolactone 100 mg daily, often combined with furosemide 40 mg daily, as the initial therapy 1.

Key Considerations

• Patients should limit sodium intake to 5 g/day or less, as recommended by recent guidelines 1.
• Diuretic therapy should be initiated with spironolactone, an aldosterone antagonist, at a dose of 100 mg daily, which can be increased to a maximum of 400 mg daily as needed 1.
• Furosemide, a loop diuretic, can be added to spironolactone if there is an insufficient response, at a starting dose of 40 mg daily, increasing to a maximum of 160 mg daily as needed 1.
• Monitoring for complications such as hyponatremia, hypokalemia, or renal dysfunction is crucial while adjusting diuretic doses 1.

Management of Diuretic-Resistant Ascites

• For patients with diuretic-resistant ascites, large-volume paracentesis (LVP) is recommended, removing 5-10 liters of fluid at once, with albumin replacement (6-8 g per liter of fluid removed) to prevent post-paracentesis circulatory dysfunction 1.
• In severe cases unresponsive to these measures, transjugular intrahepatic portosystemic shunt (TIPS) may be considered to reduce portal hypertension, though it carries risks of hepatic encephalopathy 1.
• For refractory cases, liver transplantation represents the definitive treatment, given its potential to address the underlying cause of ascites, portal hypertension, and improve quality of life and survival 1.

Ongoing Care

• Regular monitoring of body weight, serum creatinine, sodium, and potassium levels is essential to adjust diuretic doses and prevent complications 1.
• The goal of treatment is to minimize ascites while maintaining the patient's quality of life and preventing complications associated with diuretic therapy and ascites itself.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, initiate spironolactone in the hospital [see Dosage and Administration (2.4) and Clinical Pharmacology (12. 3)] . Spironolactone can cause sudden alterations of fluid and electrolyte balance which may precipitate impaired neurological function, worsening hepatic encephalopathy and coma in patients with hepatic disease with cirrhosis and ascites. WARNINGS In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis.

The treatment for worsening ascites in liver cirrhosis involves:

• Initiating spironolactone in the hospital, with careful monitoring of fluid and electrolyte balance to avoid precipitating hepatic encephalopathy and coma 2.
• Initiating furosemide therapy in the hospital, with strict observation during the period of diuresis to avoid sudden alterations of fluid and electrolyte balance that may precipitate hepatic coma 3.
• Key considerations:
  • Monitor renal function and potassium levels closely.
  • Start with the lowest initial dose and titrate slowly.
  • Supplemental potassium chloride and an aldosterone antagonist may be helpful in preventing hypokalemia and metabolic alkalosis.

From the Research

Treatment Options for Worsening Ascites

• Mild to moderate ascites is treated by salt restriction and diuretic therapy, with spironolactone being the diuretic of choice 4, 5
• A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone 4, 5
• Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy 4, 6, 7

Refractory Ascites Treatment

• Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function 4, 5, 7
• Peritoneovenous shunt is also an effective treatment of ascites in cirrhosis, especially indicated in patients who do not respond to diuretics and develop repeated episodes of ascites despite adequate treatment 6
• Liver transplantation should be considered in all patients with ascites and liver cirrhosis, as it is the only modality that is associated with improved survival 4, 5, 7

Complications and Prevention

• Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS) 4, 8
• SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm(3) and is treated with antibiotics, such as third-generation cephalosporins 8
• Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis, such as long term administration of norfloxacin 8