What is the best approach to manage ascites in a patient with cirrhosis, normal liver function tests, and impaired renal function requiring dialysis?

From the Guidelines

The most effective approach to managing ascites in a patient with cirrhosis, normal liver function tests, and impaired renal function requiring dialysis involves a combination of large-volume paracentesis, sodium restriction, and optimization of dialysis, with cautious use of diuretics and consideration for transjugular intrahepatic portosystemic shunt (TIPS) placement or liver-kidney transplantation in refractory cases. When managing ascites in such patients, it's crucial to prioritize interventions that minimize morbidity, mortality, and improve quality of life. Key considerations include:

• Large-volume paracentesis (LVP) as the primary intervention for symptom relief, accompanied by intravenous albumin administration (6-8 g per liter of fluid removed) to prevent post-paracentesis circulatory dysfunction, as recommended by 1.
• Sodium restriction to less than 5 g/day (sodium 2 g/day, 88 mmol/day) is essential, as indicated by 1, though fluid restriction is generally unnecessary unless severe hyponatremia is present.
• Diuretics like spironolactone and furosemide should be used cautiously or avoided altogether due to the patient's dialysis dependence, as they may worsen electrolyte imbalances and are often ineffective in advanced renal failure, a consideration supported by the guidance in 1.
• The dialysis prescription should be optimized to achieve appropriate fluid removal goals, taking into account the patient's overall volume status and electrolyte balance.
• For refractory cases, TIPS placement may be considered if the patient has preserved liver function, though this carries increased risks of hepatic encephalopathy, as noted in 1.
• Ultimately, these patients should be evaluated for combined liver-kidney transplantation as a definitive treatment, as the dual organ failure significantly increases mortality risk, emphasizing the need for a multidisciplinary approach that considers the patient's renal and hepatic function, as well as their overall health status and quality of life, in line with the recommendations from 1 and 1.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, furosemide 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 best approach to manage ascites in a patient with cirrhosis, normal liver function tests, and impaired renal function requiring dialysis is to initiate furosemide therapy in the hospital with strict observation to monitor for potential complications, such as hepatic coma and electrolyte imbalance.

• Supplemental potassium chloride and an aldosterone antagonist may be helpful in preventing hypokalemia and metabolic alkalosis.
• Furosemide should be used with caution in patients with impaired renal function, and discontinued if increasing azotemia and oliguria occur 2.

From the Research

Management of Ascites in Cirrhosis

The management of ascites in a patient with cirrhosis, normal liver function tests, and impaired renal function requiring dialysis involves a multi-step approach.

• The initial step is to restrict sodium intake to 2 grams per day, as sodium and water retention is the basic abnormality leading to ascites formation 3.
• Enhancement of sodium excretion can be accomplished by the usage of oral diuretics, with the recommended initial dose being spironolactone 100-200 mg/d and furosemide 20-40 mg/d 3.
• The recommended weight loss in patients without peripheral edema is 300 to 500 g/d, with no limit to the daily weight loss of patients who have edema 3.
• 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 or when there is an inability to reach maximal dose of diuretics because of adverse effects 3.

Treatment Options for Refractory Ascites

For patients with refractory ascites, treatment options include:

• Serial therapeutic paracentesis, which is the treatment of choice for cirrhotic patients with tense ascites, especially when associated with intravenous albumin infusion to prevent complications such as hepatic encephalopathy, renal impairment, and hyponatremia 4.
• Transjugular intrahepatic portosystemic shunting (TIPS), which should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver functions 3.
• Peritoneovenous shunt, which is 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, although its use is limited by the high incidence of complications induced by the procedure 4.
• Liver transplantation, which is the only modality that is associated with improved survival 3.
• Octreotide treatment, which may improve renal function and hemodynamics and diuretic response in patients with refractory ascites, although more research is needed to confirm its efficacy 5.

Diuretic Therapy

Diuretic therapy is a crucial component of ascites management, with spironolactone being the basic drug for the treatment of ascites due to its greater natriuretic potency in patients with marked sodium retention 4.

• The simultaneous administration of spironolactone and furosemide increases the natriuretic effect of each drug and diminishes their effects on potassium metabolism 4.
• Spironolactone alone seems to be as safe and effective as spironolactone associated with furosemide in the treatment of moderate ascites, and may be more suitable for treating ascites on an outpatient basis due to the need for less dose adjustment 6.