What are the Indian guidelines for managing ascites in cirrhosis?

Indian Guidelines for Managing 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

Classification and Initial Approach

Ascites in cirrhosis is classified into three grades:

• Grade 1 (Mild): Detectable only by ultrasound
• Grade 2 (Moderate): Moderate symmetrical distension
• Grade 3 (Large): Marked abdominal distension

Dietary Recommendations

• Implement moderate salt restriction (5-6.5g/day or 87-113 mmol sodium)
• Recommend a no-added salt diet with avoidance of precooked meals 1
• Ensure adequate protein intake (1.2-1.5 g/kg/day)
• Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers

Pharmacological Management

First-Line Treatment

• Spironolactone monotherapy:
  • Starting dose: 100 mg/day (can be initiated at 50-100 mg/day)
  • Can be increased up to 400 mg/day as needed
  • In cirrhosis, initiate therapy in a hospital setting and titrate slowly 2

Second-Line/Combination Therapy

• Add furosemide when:
  • Spironolactone alone is insufficient
  • Faster diuresis is needed
  • For recurrent or severe ascites
• Combination therapy:
  • Maintain 100 mg:40 mg ratio of spironolactone to furosemide
  • Spironolactone: 100-400 mg/day
  • Furosemide: 40-160 mg/day 1

Important: Starting with loop diuretics alone is not recommended and may lead to electrolyte imbalances 1. In patients with hepatic cirrhosis, furosemide therapy should be initiated in the hospital setting due to risk of sudden alterations in fluid and electrolyte balance that may precipitate hepatic coma 3.

Monitoring and Dose Adjustments

Weight Loss Targets

• Without peripheral edema: 0.5 kg/day
• With peripheral edema: No strict limit, but monitor closely 1

Laboratory Monitoring

• Regular monitoring of serum electrolytes, creatinine, and weight
• Consider spot urine Na/K ratio to assess natriuresis

Dose Adjustments

Reduce or discontinue spironolactone in cases of:

• Hyperkalemia
• Severe hyponatremia (serum sodium <125 mmol/L)
• Acute kidney injury
• Overt hepatic encephalopathy
• Severe muscle spasms

Management of Hyponatremia

• Serum sodium 126-135 mmol/L: Continue diuretic therapy with close monitoring
• Serum sodium 121-125 mmol/L with normal creatinine: Consider stopping diuretics or reducing dose
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics and give volume expansion
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion 1

Management of Refractory Ascites

Refractory ascites occurs in approximately 10% of patients and is defined as:

• Diuretic-resistant: Unresponsive to sodium restriction and high-dose diuretics
• Diuretic-intractable: Unable to reach maximal doses due to adverse effects

Therapeutic Options

1. Large Volume Paracentesis (LVP):

   • First-line treatment for refractory ascites
   • For paracentesis >5L: Infuse albumin (8 g/L of ascites removed)
   • Consider albumin infusion even for paracentesis <5L in patients with acute-on-chronic liver failure 1

2. Transjugular Intrahepatic Portosystemic Shunt (TIPSS):

   • Consider for patients with truly refractory ascites
   • Contraindications/Cautions:
     • 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

3. Adjunctive Therapies:

   • Midodrine may be considered on a case-by-case basis, though evidence is limited 1

Special Considerations

Spontaneous Bacterial Peritonitis (SBP) Prevention

• Primary prophylaxis for high-risk patients (ascitic protein <1.5 g/dL):
  • Antibiotic choice guided by local resistance patterns
• Secondary prophylaxis after recovery from SBP:
  • Consider norfloxacin (400 mg once daily)
  • Ciprofloxacin (500 mg once daily)
  • Co-trimoxazole (800 mg sulfamethoxazole and 160 mg trimethoprim daily) 1

Liver Transplantation

• All patients with ascites should be evaluated for liver transplantation, as it offers definitive treatment 1

Common Pitfalls and Caveats

• Avoid starting with loop diuretics alone
• Avoid overly rapid correction of hyponatremia (not exceeding 12 mmol/L per 24 hours)
• Avoid fluid restriction unless severe hyponatremia is present
• Monitor non-selective beta-blockers closely in patients with refractory ascites
• Remember that routine measurement of prothrombin time and platelet count before paracentesis is not recommended 1