What are the Indian Society guidelines for managing ascites?

Management of Ascites in Cirrhosis: Indian Society Guidelines

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

Initial Diagnostic Evaluation

• Ascitic fluid analysis should include:
  • Serum-ascites albumin gradient (SAAG) rather than ascitic protein 2, 1
  • Neutrophil count with microscopy 2
  • Ascitic fluid inoculation into blood culture bottles at bedside 2
  • Ascitic amylase when pancreatic disease is suspected 2

Dietary Management

• Implement moderate salt restriction with daily intake of 90 mmol salt/day (5.2 g salt/day) 2, 1
• Adopt a no-added salt diet with avoidance of pre-prepared foodstuffs 2, 1
• Provide protein supplementation (1.2-1.5 g/kg/day) 1
• Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers 1

Diuretic Therapy

First-Line Treatment

• Start with spironolactone monotherapy at 100 mg/day 1
  • Mechanism: Antagonizes aldosterone, increasing sodium and water excretion while retaining potassium 3
  • Can be titrated up to maximum of 400 mg/day 1

Second-Line Treatment

• Add furosemide (starting at 40 mg/day) for recurrent or severe ascites 1
  • Maintain 100 mg:40 mg ratio of spironolactone to furosemide 1
  • Avoid starting with loop diuretics alone (risk of electrolyte imbalances) 1
  • In hepatic cirrhosis, furosemide therapy should be initiated in hospital setting 4

Monitoring During Diuretic Therapy

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

Management of Complications

Hyponatremia Management

• Serum sodium 126-135 mmol/L: Continue diuretics with close monitoring 2, 1
• Serum sodium 121-125 mmol/L with normal creatinine: Consider reducing or stopping diuretics 2, 1
• Serum sodium 121-125 mmol/L with elevated creatinine: Stop diuretics and give volume expansion 2, 1
• Serum sodium <120 mmol/L: Stop diuretics and consider volume expansion 2, 1
• Fluid restriction (1-1.5 L/day) only for severe hyponatremia (<125 mmol/L) 1

Hyperkalemia

• Monitor serum potassium within 1 week of starting spironolactone and regularly thereafter 3
• If hyperkalemia occurs, decrease dose or discontinue spironolactone 3

Management of Refractory Ascites

Large Volume Paracentesis (LVP)

• Obtain informed consent and consider ultrasound guidance 1
• For paracentesis >5L: Infuse albumin (8 g/L of ascites removed) 1
• Consider albumin infusion even for paracentesis <5L in patients with acute-on-chronic liver failure 1

Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

• Consider for truly refractory ascites 1
• 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

Special Considerations

• Bed rest is not generally recommended for uncomplicated ascites 2
• Water restriction is not recommended for uncomplicated ascites 2
• All patients with ascites should be evaluated for liver transplantation 1, 5
• Consider prophylactic antibiotics for patients with gastrointestinal bleeding and ascites 1
• For spontaneous bacterial peritonitis (SBP), infuse albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 1

Common Pitfalls to Avoid

• Overly rapid diuresis leading to electrolyte imbalances and renal dysfunction
• Starting with loop diuretics alone instead of spironolactone
• Excessive water restriction in patients with uncomplicated ascites
• Overly rapid correction of hyponatremia (avoid increasing serum sodium by >12 mmol/L per 24 hours) 1
• Failure to monitor for diuretic-related complications (hyperkalemia with spironolactone, hypokalemia with furosemide)
• Delayed referral for liver transplantation evaluation