What is the treatment for ascites due to liver cirrhosis?

Treatment of Ascites Due to Liver Cirrhosis

First-line treatment for patients with cirrhosis and ascites consists of dietary sodium restriction (88 mmol/day [2000 mg/day]) and oral diuretics (spironolactone and furosemide). 1

Initial Assessment and Treatment Approach

First-line Management:

• Dietary sodium restriction to 88 mmol/day (2000 mg/day or approximately 5g salt/day) - this is equivalent to a "no added salt" diet 1
• Oral diuretics are the mainstay of pharmacological treatment 1
  • Start with spironolactone 100 mg once daily 1, 2
  • Add furosemide 40 mg once daily if needed 1, 3
• Doses can be increased simultaneously every 3-5 days (maintaining the 100 mg:40 mg ratio) if weight loss and natriuresis are inadequate 1
• Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide 1

For Patients with Tense Ascites:

• Initial therapeutic abdominal paracentesis should be performed 1
• Follow with sodium restriction and oral diuretics as described above 1

Special Considerations

Fluid Restriction:

• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 1
• Hyponatremia usually seen in cirrhotic ascites patients is seldom morbid 1

Alcohol-Related Cirrhosis:

• Patients with ascites who have an alcohol component to their liver injury should abstain from alcohol consumption 1
• Abstinence can result in dramatic improvement in the reversible component of alcoholic liver disease 1

Nutritional Management:

• Recommended nutritional intake: 2-3 g/kg/day carbohydrate, 1.2-1.5 g/kg/day protein, and 35-40 kcal/kg/day 1
• Smaller, frequent meals may be beneficial if three meals per day do not provide adequate nutrition 1
• A late-evening snack of 200 kcal can improve nutritional status 1

Monitoring and Follow-up

• Monitor serum electrolytes, creatinine, and weight regularly 1
• Measure 24-hour urinary sodium excretion if weight loss is less than desired 1
• Frequency of follow-up is determined by response to treatment and stability of the patient 1
• Some patients warrant evaluation every 2-4 weeks until response is established 1

Management of Refractory Ascites

Refractory ascites is defined as fluid overload that:

1. Is unresponsive to sodium-restricted diet and high-dose diuretic treatment (400 mg/day spironolactone and 160 mg/day furosemide), or
2. Recurs rapidly after therapeutic paracentesis 1

Treatment Options for Refractory Ascites:

• Serial therapeutic paracenteses (every 2-3 weeks as needed) 1, 4
• Transjugular intrahepatic portosystemic stent-shunt (TIPS) in selected patients 1, 4, 5
• Liver transplantation should be considered 1, 6

Important Considerations:

• Avoid nonsteroidal anti-inflammatory drugs as they can reduce urinary sodium excretion and induce azotemia 1
• For large-volume paracentesis (>5L), albumin infusion (8g/L of ascites removed) is recommended to prevent circulatory dysfunction 1, 4
• Liver transplantation offers a definitive cure for cirrhosis and its complications 1, 6

Pitfalls and Caveats

• Bed rest is not recommended for the treatment of ascites 1
• Excessive sodium restriction (<88 mmol/day) may worsen malnutrition 1
• Rapid correction of hyponatremia with hypertonic saline can lead to more complications than the hyponatremia itself 1
• Furosemide can cause sudden alterations of fluid and electrolyte balance in patients with cirrhosis and may precipitate hepatic coma 3
• Development of ascites is associated with poor prognosis - 20% of those presenting with ascites die in the first year of diagnosis 1