What is the management approach for a patient with ascites following Balloon-Occluded Retrograde Transvenous Obliteration (BRTO)?

Management of Ascites Following BRTO

The management of ascites following Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) should focus on sodium restriction (88-90 mmol/day) and diuretic therapy with spironolactone (starting at 100 mg/day) and furosemide (starting at 40 mg/day), with dose titration as needed.

Understanding Post-BRTO Ascites

Ascites development or exacerbation following BRTO is a known complication that occurs in approximately:

• 15% of patients requiring intervention within the first year
• 35-40% of patients showing ascites on imaging 1

This complication occurs because BRTO obliterates the gastro-renal shunt, which increases portal pressure and redirects blood flow to the liver. While this can improve liver synthetic function, it can also lead to portal hypertension complications including ascites.

Initial Assessment

When managing ascites after BRTO, evaluate:

• Severity of ascites (mild, moderate, tense)
• Presence of symptoms (abdominal discomfort, dyspnea, early satiety)
• Electrolyte abnormalities (particularly sodium and potassium)
• Renal function (serum creatinine)
• Liver function tests

Treatment Algorithm

First-Line Treatment

1. Dietary sodium restriction

   • Limit to 88-90 mmol/day (2000 mg/day) 1, 2
   • Avoid pre-prepared foods with high sodium content
   • Protein supplementation (1.2-1.5 g/kg/day) is recommended 2

2. Diuretic therapy

   • Start with spironolactone 100 mg once daily 1, 2
   • Add furosemide 40 mg once daily if response is inadequate 1, 2
   • Titrate doses upward every 3-5 days as needed (maintaining 100:40 mg ratio)
   • Maximum doses: spironolactone 400 mg/day, furosemide 160 mg/day 1

3. Fluid restriction

   • Only necessary if serum sodium <125 mmol/L 1, 2
   • Restrict to 1-1.5 L/day in severe hyponatremia 2

For Tense Ascites

If the patient has tense ascites causing significant discomfort:

1. Large-volume paracentesis (LVP)

   • Rapidly relieves symptoms
   • For paracentesis >5L: administer IV albumin (8 g/L of ascites removed) 1, 3
   • Follow with dietary sodium restriction and diuretic therapy to prevent reaccumulation 1

2. Post-paracentesis management

   • Continue sodium restriction
   • Optimize diuretic therapy
   • Monitor electrolytes, renal function, and weight

Monitoring and Adjustments

Monitor patients for:

• Weight changes (target 0.5 kg/day loss without peripheral edema) 2
• Serum electrolytes (sodium, potassium)
• Renal function
• Development of complications

Temporarily discontinue diuretics if:

• Serum sodium <125 mmol/L
• Significant hypokalemia or hyperkalemia
• Serum creatinine >2.0 mg/dL
• Hepatic encephalopathy
• Severe muscle cramps 2

Management of Refractory Ascites

If ascites becomes refractory to standard therapy (defined as unresponsive to sodium restriction and high-dose diuretics or rapid recurrence after paracentesis):

1. Serial therapeutic paracenteses

   • Performed approximately every 2 weeks
   • Administer IV albumin (8 g/L of fluid removed) for paracentesis >5L 1

2. Consider TIPS evaluation

   • Particularly if requiring frequent paracenteses
   • 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 2

3. Liver transplantation evaluation

   • Should be considered for all eligible patients with cirrhosis and ascites 2, 4

Special Considerations for Post-BRTO Patients

1. Monitor for esophageal varices

   • BRTO can exacerbate esophageal varices in 30-35% of patients 1
   • Perform EUS within 48 hours after BRTO to evaluate for varices 1
   • Schedule repeat upper endoscopy within 2 weeks for high-risk EV and within 4-6 weeks for low-risk EV 1

2. Follow-up imaging

   • Contrast-enhanced CT or MRI at 4-6 weeks post-procedure
   • Additional imaging at 3 and 6 months 1

3. Avoid nephrotoxic medications

   • NSAIDs, ACE inhibitors, and angiotensin receptor blockers should be avoided 2

Common Pitfalls and Caveats

1. Overdiuresis

   • Can lead to hyponatremia, hypokalemia, or renal dysfunction
   • Monitor electrolytes and renal function regularly

2. Inadequate albumin replacement

   • For large-volume paracentesis (>5L), albumin administration (8 g/L of ascites removed) is essential to prevent post-paracentesis circulatory dysfunction 3

3. Ignoring other complications

   • Monitor for development or worsening of esophageal varices
   • Watch for signs of hepatic encephalopathy (which typically improves after BRTO) 1

4. Medication compliance

   • Ensure patient understands the importance of sodium restriction
   • Single morning dosing of diuretics maximizes compliance 1

By following this structured approach to managing ascites after BRTO, clinicians can effectively control this common complication while monitoring for and preventing potential adverse events.