What is the initial treatment for ascites?

Initial Treatment of Ascites in Cirrhosis

The initial treatment for ascites in cirrhosis should include sodium restriction (2g or 90 mmol/day) combined with spironolactone starting at 100 mg/day as first-line diuretic therapy, which can be progressively increased up to 400 mg/day if needed. 1, 2

Diagnostic Approach

• A diagnostic paracentesis should be performed in all patients with new-onset ascites that is accessible for sampling 1
• Initial laboratory investigation of ascitic fluid should include:
  • Ascitic fluid neutrophil count
  • Ascitic fluid total protein
  • Ascitic fluid albumin and serum albumin to calculate serum-ascites albumin gradient (SAAG) 1

Treatment Algorithm

Step 1: Dietary Sodium Restriction

• Implement moderate dietary sodium restriction (2g or 90 mmol/day) 1, 2
• Patient education is essential for adherence while avoiding malnutrition 1
• Consider formal consultation with a dietician 1
• Fluid restriction is NOT indicated unless hyponatremia is present 1, 2

Step 2: Diuretic Therapy

• First-line treatment: Spironolactone alone starting at 100 mg/day 1

  • Mechanism: Aldosterone antagonist acting on distal tubules to increase natriuresis and conserve potassium 3
  • Can be progressively increased up to 400 mg/day if needed 1
  • Allow at least 72 hours between dose increases due to long half-life 1

• Second-line (add if spironolactone alone is insufficient): Furosemide starting at 40 mg/day 1

  • Can be progressively increased up to 160 mg/day 1
  • Use cautiously in patients with cirrhosis as sudden alterations of fluid and electrolyte balance may precipitate hepatic coma 4

Monitoring and Adjustments

• Monitor serum electrolytes, creatinine, and weight regularly 1, 2
• Target weight loss:
  • Patients without peripheral edema: 0.5 kg/day 2
  • Patients with peripheral edema: up to 1 kg/day may be tolerated 1
• Assess 24-hour urinary sodium excretion or spot urine Na/K ratio to guide therapy 1
  • Spot urine Na/K ratio >1: Patient should be losing fluid weight 1
  • Spot urine Na/K ratio ≤1: Insufficient natriuresis, consider increasing diuretics 1

Management of Complications and Special Situations

Hyponatremia Management

• Serum sodium 126-135 mmol/L: Continue diuretics with close monitoring 1, 2
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics or reducing dose 1, 2
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion 1, 2
  • Avoid increasing serum sodium by >12 mmol/L per 24 hours 1

Diuretic-Related Adverse Effects (occur in 20-40% of patients) 1, 2

• Hyperkalemia: Reduce or discontinue spironolactone
• Hypokalemia: Reduce or discontinue furosemide
• Gynecomastia: Consider switching from spironolactone to amiloride or eplerenone 1
• Muscle cramps: Correct electrolyte abnormalities; consider baclofen (10 mg/day, increased weekly up to 30 mg/day) 1

Refractory Ascites

If ascites fails to respond to maximum doses of diuretics (spironolactone 400 mg/day plus furosemide 160 mg/day) for at least one week, it is considered refractory 2 and requires:

• Therapeutic paracentesis with albumin infusion (8g/L of ascites removed for paracentesis >5L) 1, 2
• Consider transjugular intrahepatic portosystemic shunt (TIPS) in appropriate candidates 1, 2
• Evaluation for liver transplantation, which is the definitive treatment 1, 2

Common Pitfalls to Avoid

• Starting with loop diuretics alone instead of spironolactone 2
• Inadequate monitoring of electrolytes and renal function 2
• Using NSAIDs, which can reduce diuretic efficacy and induce renal dysfunction 2
• Unnecessary fluid restriction in patients without severe hyponatremia 2
• Excessive diuresis leading to renal dysfunction 2

The development of ascites is a poor prognostic sign in cirrhosis, with only 50% of patients surviving 2-5 years after its development 5. Therefore, all patients with ascites should be considered for liver transplantation evaluation 1, 2.