What is the management plan for recurrent ascites?

From the Guidelines

The management plan for recurrent ascites primarily involves sodium restriction, diuretic therapy, and periodic large-volume paracentesis, with the most recent and highest quality evidence recommending combination therapy with spironolactone and furosemide for patients with recurrent severe ascites. Patients should limit sodium intake to 2000 mg daily. First-line diuretic therapy typically combines spironolactone (starting at 100 mg daily) with furosemide (starting at 40 mg daily), which can be titrated up as needed to a maximum of spironolactone 400 mg and furosemide 160 mg daily, as recommended by the guidelines on the management of ascites in cirrhosis 1.

Key Components of Management

• Sodium restriction to 2000 mg daily
• Diuretic therapy with spironolactone and furosemide
• Periodic large-volume paracentesis for patients who don't respond adequately to diuretics
• Intravenous albumin administration when more than 5 liters of fluid are removed to prevent circulatory dysfunction

Considerations for Refractory Cases

For patients with refractory ascites, repeated large-volume paracentesis plus albumin (8 g/L of ascites removed) is the first line of treatment, and diuretics should be discontinued in patients who do not excrete >30 mmol/day of sodium under diuretic treatment 1. Transjugular intrahepatic portosystemic shunt (TIPS) placement may be considered in appropriate candidates, but it is associated with a high risk of hepatic encephalopathy and has not been shown to convincingly improve survival compared to repeated large-volume paracentesis 1.

Monitoring and Complications

Throughout treatment, patients should be monitored for complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and electrolyte imbalances, as recommended by the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis 1. This multi-faceted approach addresses the underlying pathophysiology of ascites, which involves portal hypertension, sodium retention, and altered hemodynamics in cirrhosis. Liver transplantation remains the definitive treatment for patients with end-stage liver disease and recurrent ascites.

From the FDA Drug Label

By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions.

• Management of Recurrent Ascites: Spironolactone is used to provide effective therapy for ascites in conditions such as hepatic cirrhosis.
• The drug acts as an aldosterone antagonist, increasing the excretion of sodium and water while retaining potassium.
• Key Considerations:
  • Monitor serum potassium levels within 1 week of initiation or titration of spironolactone and regularly thereafter 2.
  • Monitor volume status and renal function periodically to avoid excessive diuresis and worsening renal function 2.
• Additional Therapy: Supplemental potassium chloride and an aldosterone antagonist, such as spironolactone, may be helpful in preventing hypokalemia and metabolic alkalosis in patients with hepatic cirrhosis and ascites 3.

From the Research

Management of Recurrent Ascites

The management of recurrent ascites involves a combination of dietary restrictions, diuretic therapy, and other interventions.

• The primary goal is to reduce sodium and water retention, which is the underlying cause of ascites formation 4.
• Patients with cirrhosis and ascites should limit their sodium intake to 2 grams per day and use oral diuretics to enhance sodium excretion 4.
• The recommended initial dose of diuretics is spironolactone 100-200 mg/d and furosemide 20-40 mg/d, with maximum doses of 400 mg/d and 160 mg/d, respectively 4.
• For patients with refractory ascites, treatment options include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), peritoneovenous shunt, and liver transplantation 4, 5, 6.

Treatment Options for Refractory Ascites

Refractory ascites is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment 4.

• TIPS should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver function 4, 7.
• Liver transplantation is the only modality associated with improved survival in patients with refractory ascites 4, 5, 7.
• Repeated large-volume paracentesis with intravenous infusion of human albumin is also an effective and safe therapy for ascites 6.

Prevention of Complications

Prevention of complications, such as spontaneous bacterial peritonitis and hepatorenal syndrome, is crucial in the management of cirrhotic patients with ascites 7, 8.

• Antibiotic prophylaxis should be given to patients at risk of developing spontaneous bacterial peritonitis 7.
• Substitution with albumin is essential to prevent hepatorenal syndrome in patients treated with large-volume paracentesis 7.