What are the guidelines for managing ascites in patients with cirrhosis (chronic liver disease)?

Management of Ascites in Cirrhosis

The management of ascites in cirrhosis should follow a stepwise approach starting with sodium restriction and diuretic therapy, with spironolactone as the primary agent, followed by the addition of furosemide for recurrent or severe ascites, and consideration of large volume paracentesis or TIPSS for refractory cases. 1, 2

Initial Management

Dietary Modifications

• Implement moderate salt restriction with daily intake of no more than 5-6.5g (87-113 mmol sodium) 1
• Provide nutritional counseling on sodium content in diet 1
• Recommend a no-added salt diet with avoidance of precooked meals 1
• Ensure adequate protein intake (1.2-1.5 g/kg/day) 2

Diuretic Therapy

• First-line approach for moderate ascites:

  • Start with spironolactone monotherapy at 100 mg/day (can be increased up to 400 mg/day) 1, 3
  • For patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly 3
  • Spironolactone alone is as effective as combination therapy for moderate ascites and requires fewer dose adjustments 4

• For recurrent severe ascites or when faster diuresis is needed:

  • Use combination therapy with spironolactone (starting at 100 mg, up to 400 mg) and furosemide (starting at 40 mg, up to 160 mg) 1, 2
  • Maintain a 100 mg:40 mg ratio of spironolactone to furosemide to maintain normal potassium levels 2

• Monitoring during diuretic therapy:

  • Target weight loss: 0.5 kg/day in patients without peripheral edema 2
  • No limit to daily weight loss when peripheral edema is present, but use caution 2
  • Monitor serum electrolytes, creatinine, and weight regularly 1, 2
  • Consider spot urine Na/K ratio to assess natriuresis 2

Management of Complications During Diuretic Therapy

Hyponatremia Management

• For hypovolemic hyponatremia: discontinue diuretics and expand plasma volume with normal saline 1
• Fluid restriction (1-1.5 L/day) should be reserved only for patients with severe hyponatremia (serum sodium <125 mmol/L) 1, 2
• For severely symptomatic acute hyponatremia: consider hypertonic sodium chloride (3%) with slow correction 1
• Avoid increasing serum sodium by >12 mmol/L per 24 hours 2

Other Complications

• Reduce or discontinue diuretics for:
  • Hyperkalemia
  • Acute kidney injury
  • Hepatic encephalopathy
  • Severe muscle cramps 2
• Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers as they can reduce diuretic efficacy and induce renal dysfunction 2

Management of Refractory Ascites

Refractory ascites is defined as ascites that fails to respond to maximum doses of diuretics (spironolactone 400 mg/day plus furosemide 160 mg/day) for at least one week 2.

Large Volume Paracentesis (LVP)

• Obtain informed consent before therapeutic paracentesis 1
• Consider ultrasound guidance to reduce adverse events 1
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 1
• For paracentesis >5L: infuse albumin (8 g/L of ascites removed) after completion 1
• For paracentesis <5L: consider albumin infusion in patients with ACLF or high risk of post-paracentesis acute kidney injury 1

Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

• Consider TIPSS for patients with truly refractory ascites 1, 2
• Use caution 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
  • Hepatorenal syndrome 1

Other Options

• Consider midodrine on a case-by-case basis for refractory ascites 1
• Evaluate all patients with ascites for liver transplantation as it offers definitive treatment 2

Management of Spontaneous Bacterial Peritonitis (SBP)

Treatment

• For SBP with increased or rising serum creatinine: infuse albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 1
• Immediate empirical antibiotic therapy based on local resistance patterns 1

Prophylaxis

• Secondary prophylaxis after recovery from SBP: consider norfloxacin (400 mg once daily), ciprofloxacin (500 mg once daily), or co-trimoxazole (800 mg sulfamethoxazole and 160 mg trimethoprim daily) 1
• Primary prophylaxis for high-risk patients (ascitic protein <1.5 g/dL): antibiotic choice guided by local resistance patterns 1
• Prophylactic antibiotics for patients with gastrointestinal bleeding and underlying ascites 1

Common Pitfalls to Avoid

• Starting with loop diuretics alone instead of spironolactone 2
• Excessive diuresis leading to renal dysfunction 2
• Inadequate monitoring of electrolytes and renal function 2
• Using NSAIDs, which can convert patients from diuretic-sensitive to refractory ascites 2
• Unnecessary fluid restriction when serum sodium is >125 mmol/L 2
• Failing to consider TIPSS in appropriate candidates with refractory ascites 1