What are the guidelines for managing ascites?

INASL Guidelines for Ascites Management

Ascites management should follow a stepwise approach, starting with sodium restriction and diuretic therapy (spironolactone as primary agent, with addition of furosemide for recurrent/severe ascites), followed by large volume paracentesis or TIPSS for refractory cases. 1

Diagnostic Evaluation

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

Dietary Management

• Restrict dietary salt to 90 mmol/day (5.2 g salt/day) by adopting a no-added salt diet 2, 1
• Avoid pre-prepared foodstuffs which typically contain high sodium content 2, 1
• Provide protein supplementation (1.2-1.5 g/kg/day) for patients with cirrhosis and ascites 1
• Avoid NSAIDs, ACE inhibitors, and angiotensin receptor blockers 1

Medication Management

First-Line Therapy

• Start with spironolactone monotherapy at 100 mg/day 1, 3
  • Can be increased up to 400 mg/day as needed 1, 4
  • Acts as an aldosterone antagonist, counteracting secondary aldosteronism 3

Second-Line/Combination Therapy

• Add furosemide (starting at 40 mg/day, up to 160 mg/day) when:
  • Faster diuresis is needed
  • Ascites is severe or recurrent
  • Maintain a 100 mg:40 mg ratio of spironolactone to furosemide to maintain normokalemia 1, 5, 4

Monitoring and Weight Loss Targets

• Monitor serum electrolytes, creatinine, and weight regularly 1
• Target weight loss:
  • 0.5 kg/day (300-500 g/day) in patients without peripheral edema 1, 4
  • No limit to daily weight loss when peripheral edema is present (but monitor carefully) 1, 4
• Monitor serum potassium within 1 week of initiation or titration of spironolactone 3

Management of Hyponatremia

• For serum sodium 126–135 mmol/l with normal creatinine: Continue diuretic therapy with monitoring 2, 1
• For serum sodium 121–125 mmol/l with normal creatinine: Consider stopping diuretics or reducing dose 2, 1
• For serum sodium 121–125 mmol/l with elevated creatinine: Stop diuretics and give volume expansion 2, 1
• For serum sodium <120 mmol/l: Stop diuretics and consider volume expansion with colloid or saline 1
• Water restriction (1-1.5 L/day) only for severe hyponatremia (serum sodium <125 mmol/L) 1

Management of Refractory Ascites

• Defined as fluid overload unresponsive to sodium restriction and high-dose diuretics, or inability to reach maximal diuretic doses due to adverse effects 4
• Treatment options:
  1. Serial large-volume paracentesis (LVP) 4, 6
     • For paracentesis >5L: Infuse albumin (8 g/L of ascites removed) after completion 1, 6
  2. Transjugular intrahepatic portosystemic shunt (TIPS) 1, 4, 6
     • Consider for patients who repeatedly fail large-volume paracentesis
     • 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, or hepatorenal syndrome 1
  3. Liver transplantation 1, 4, 7
     • Should be considered for all patients with ascites as it offers definitive treatment

Complications and Prevention

• Spontaneous bacterial peritonitis (SBP):

  • Rule out infection in all hospitalized patients with ascites 7
  • For confirmed SBP: Infuse albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3 1
  • Consider prophylactic antibiotics for high-risk patients (ascitic protein <1.5 g/dL) 1, 7

• Hepatorenal syndrome:

  • Avoid excessive diuresis which may cause symptomatic dehydration, hypotension and worsening renal function 3
  • Monitor renal function periodically, especially in patients taking nephrotoxic drugs 3

• Electrolyte abnormalities:

  • Monitor for hyperkalemia, hyponatremia, hypomagnesemia, hypocalcemia, and hypochloremic alkalosis 3
  • Reduce or discontinue spironolactone in cases of hyperkalemia 3

The management of ascites requires a structured approach with careful monitoring of electrolytes and renal function to prevent complications while achieving effective diuresis.