How to manage hypotension in patients with ascites and cirrhosis?

Management of Hypotension in Patients with Ascites and Cirrhosis

In patients with cirrhosis and ascites who develop hypotension, avoid angiotensin-converting enzyme inhibitors and other vasodilators as they can aggravate hypotension without clinical benefit. 1

Pathophysiology and Risk Assessment

• Hypotension in cirrhosis with ascites often results from splanchnic vasodilation, decreased effective arterial blood volume, and activation of the renin-angiotensin-aldosterone system 2
• Upright posture may aggravate plasma renin elevation in cirrhotic patients with ascites, potentially worsening sodium retention and hypotension 1
• Patients without peripheral edema who undergo large volume paracentesis (>7.5 liters) are at highest risk for developing severe clinical hypotension 3

Management Algorithm

First-line Approach

1. Avoid medications that worsen hypotension

   • Discontinue angiotensin-converting enzyme inhibitors, which aggravate hypotension in cirrhotic patients 1
   • Avoid nonsteroidal anti-inflammatory drugs as they reduce urinary sodium excretion and can induce azotemia 1, 4

2. Optimize diuretic regimen

   • Use combination of spironolactone and furosemide starting at 100 mg and 40 mg respectively as a single morning dose 1, 4
   • Temporarily withhold furosemide in patients presenting with hypokalemia 1
   • Adjust diuretic doses based on blood pressure response, maintaining the 100 mg:40 mg ratio of spironolactone to furosemide 1, 4

3. Volume management

   • For large-volume paracentesis (>5L), administer intravenous albumin (8 g/L of fluid removed) to prevent circulatory dysfunction and worsening hypotension 1, 4
   • Volume expanders should be introduced before the 4th hour from the start of large volume paracentesis 3

Management of Hyponatremia with Hypotension

• Fluid restriction is generally not necessary unless serum sodium is less than 120-125 mmol/L 1, 4
• Avoid rapid correction of hyponatremia with hypertonic saline as this can lead to more complications than the hyponatremia itself 1
• Consider aquaretic agents (vasopressin receptor antagonists) for severe hyponatremia, though evidence for their efficacy without side effects remains limited 1

Refractory Cases

• For patients with refractory ascites and persistent hypotension, consider:
  • Serial therapeutic paracenteses with albumin supplementation 1, 5
  • Transjugular intrahepatic portosystemic shunt (TIPS) in selected patients without contraindications 4, 2
  • Evaluation for liver transplantation, which offers definitive treatment 4, 2

Special Considerations and Pitfalls

• Alcohol cessation is critical: In patients with alcoholic liver disease, abstinence can dramatically improve the reversible component of liver disease and ascites management 1, 4
• Bed rest is not supported by evidence: Despite traditional recommendations, there are no controlled trials supporting bed rest for management of hypotension in cirrhotic patients 1
• Monitoring parameters: Regularly assess blood pressure, serum electrolytes, creatinine, and weight to guide therapy adjustments 4
• Avoid vasodilators: Many drugs with theoretical promise in treating ascites (e.g., ACE inhibitors) have been shown to aggravate hypotension and should be avoided 1
• Paracentesis-induced circulatory dysfunction: This can occur 4-62 hours after large volume paracentesis, requiring close monitoring beyond the immediate post-procedure period 3

Prognosis

• Development of ascites with hypotension indicates poor prognosis - approximately 50% of patients die within 2 years without liver transplantation 2, 6
• Patients with refractory ascites and hypotension should be evaluated for liver transplantation as it offers the most definitive cure 4, 5