What is the appropriate management for a patient with cirrhosis due to Hepatitis C (HCV) infection presenting with refractory ascites?

Management of Refractory Ascites in Cirrhosis

The most appropriate management for a patient with cirrhosis due to hepatitis C infection presenting with ascites that did not respond to repeated paracentesis is salt restriction (D. Restrict salt intake). 1

First-Line Management for Refractory Ascites

Dietary Sodium Restriction

• Patients with cirrhosis and ascites should have a moderately salt restricted diet with daily salt intake of no more than 5-6.5g (87-113 mmol sodium) 1
• This translates to a no-added salt diet with avoidance of precooked meals
• Nutritional counseling regarding sodium content in diet is strongly recommended 1, 2

Diuretic Therapy

• For patients with refractory ascites, maximum diuretic therapy should be attempted:
  • Spironolactone: starting at 100mg/day, can be increased up to 400mg/day 1, 2
  • Furosemide: starting at 40mg/day, can be increased up to 160mg/day 1, 2
• Monitor for adverse events, as almost half of patients may require dose reduction or discontinuation 1

Advanced Management Options

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

• TIPS should be strongly considered in patients with truly refractory ascites 1, 2
• Caution is required in patients with:
  • Age >70 years
  • Serum bilirubin >50 μmol/L
  • Platelet count <75×10^9/L
  • MELD score ≥18
  • Current hepatic encephalopathy
  • Active infection or hepatorenal syndrome 1

Large Volume Paracentesis (LVP)

• For patients who have failed diuretic therapy, serial therapeutic paracenteses are effective 1, 2
• Albumin (20% or 25% solution) should be infused after paracentesis of >5L at a dose of 8g albumin/L of ascites removed 1, 2
• Consider albumin infusion even for paracentesis <5L in patients with acute-on-chronic liver failure 1

Important Considerations and Pitfalls

Fluid Restriction

• Fluid restriction is NOT necessary unless serum sodium is less than 120-125 mmol/L 1
• When required, restrict to 1-1.5 L/day only in patients with severe hyponatremia 1

Protein Intake

• High protein diet is NOT contraindicated and should be encouraged in cirrhotic patients
• Protein restriction should be avoided as it can worsen malnutrition, which is common in cirrhosis 2

Medications to Avoid

• NSAIDs should be strictly avoided as they can reduce diuretic efficacy and induce renal dysfunction 2
• Prostaglandin inhibitors can convert patients from diuretic-sensitive to refractory ascites 1

Monitoring

• Regular monitoring of serum electrolytes, particularly during the first weeks of treatment 2
• Target weight loss of ≤0.5 kg/day without peripheral edema and up to 1 kg/day with edema 2

Long-term Management

• All patients with refractory ascites should be evaluated for liver transplantation, as it offers definitive treatment 1, 2, 3
• In selected cases, midodrine may be considered for refractory ascites, though evidence is limited 1, 4

The management of refractory ascites requires a systematic approach with salt restriction as the cornerstone of therapy, alongside appropriate diuretic management and consideration of invasive options like TIPS when necessary.