What is the initial management of ascites in cirrhosis, including the role of albumin and diuretics?

Management of Ascites in Cirrhosis: Role of Albumin and Diuretics

The initial management of ascites in cirrhosis should include sodium restriction (88-90 mmol/day), spironolactone (starting at 100 mg/day, increasing to 400 mg/day if needed), and the addition of furosemide (starting at 40 mg/day, increasing to 160 mg/day) for patients with recurrent or severe ascites. 1

First-Line Management Algorithm

Step 1: Dietary Modifications

• Implement a no-added salt diet (5.2 g salt/day or 90 mmol sodium/day) 1
• Fluid restriction is NOT necessary unless serum sodium is <125 mmol/L 1

Step 2: Diuretic Therapy

• For initial or mild ascites:

  • Start with spironolactone monotherapy at 100 mg/day 1
  • Increase gradually up to 400 mg/day if needed (allow 3-5 days between dose adjustments) 1

• For recurrent or severe ascites:

  • Combination therapy with spironolactone (100-400 mg/day) and furosemide (40-160 mg/day) 1
  • Maintain a 100 mg:40 mg ratio of spironolactone to furosemide to maintain normokalemia 1
  • Single morning dosing maximizes compliance 1

Step 3: Monitoring During Diuretic Therapy

• Monitor serum electrolytes, creatinine, and weight regularly 1, 2
• Almost half of patients experience adverse events requiring dose reduction or discontinuation 1
• Common complications include electrolyte disturbances, renal impairment, and hepatic encephalopathy 2

Management of Tense Ascites

Large Volume Paracentesis (LVP)

• For patients with tense ascites, perform therapeutic paracentesis followed by diuretic therapy 1
• Albumin administration is crucial:
  • For paracentesis >5L: Infuse albumin (8 g/L of ascites removed) after the procedure is completed 1
  • For paracentesis <5L: Consider albumin (8 g/L) in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1
• Ultrasound guidance should be considered during LVP to reduce adverse events 1
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 1

Management of Hyponatremia During Treatment

• Serum sodium 126-135 mmol/L: Continue diuretic therapy with close monitoring 1
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics or reducing dose 1
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics and give volume expansion 1
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion with colloid or saline 1
• Fluid restriction (1-1.5 L/day) only for severe hyponatremia (<125 mmol/L) in hypervolemic patients 1

Special Considerations

Spontaneous Bacterial Peritonitis (SBP)

• In patients with SBP and increased or rising serum creatinine, albumin infusion is recommended:
  • 1.5 g albumin/kg within 6 hours of diagnosis
  • Followed by 1 g/kg on day 3 1

Refractory Ascites

• Consider transjugular intrahepatic portosystemic shunt (TIPSS) 1, 2
• Use caution with TIPSS in patients with age >70 years, bilirubin >50 μmol/L, platelets <75×10^9/L, MELD score ≥18, hepatic encephalopathy, active infection, or hepatorenal syndrome 1
• Midodrine may be considered on a case-by-case basis 1

Medications to Avoid

• NSAIDs and other prostaglandin inhibitors can reduce diuretic efficacy and induce renal dysfunction 1, 3
• These medications can convert patients from diuretic-sensitive to refractory ascites 2

Long-term Management

• All patients with ascites should be evaluated for liver transplantation, as it offers definitive treatment 1, 2
• Non-selective beta-blockers should not be viewed as a contraindication in patients with refractory ascites, but require close monitoring 1

Common Pitfalls to Avoid

• Overly rapid correction of hyponatremia (avoid increasing serum sodium by >12 mmol/L per 24 hours) 1
• Failure to provide albumin with large-volume paracentesis, which can lead to post-paracentesis circulatory dysfunction 4
• Inadequate monitoring of electrolytes and renal function during diuretic therapy 1
• Delaying referral for liver transplantation evaluation 2