What is the best approach to fluid management in patients with chronic liver disease?

Fluid Management in Chronic Liver Disease

The optimal approach to fluid management in chronic liver disease involves dietary sodium restriction (5-6.5g/day), spironolactone as first-line diuretic therapy (starting at 100mg daily), with addition of furosemide for refractory cases, and large volume paracentesis with albumin replacement for tense ascites. 1

Dietary Management

• Patients with cirrhosis and ascites should follow a moderately salt-restricted diet with daily salt intake of no more than 5-6.5g (87-113 mmol sodium), which translates to a no-added salt diet with avoidance of precooked meals 1
• Nutritional counseling on sodium content in diet is strongly recommended 1
• Fluid restriction is generally not necessary unless serum sodium is <125 mmol/L 1

Diuretic Therapy

Initial Approach

• For first presentation of moderate ascites, start with spironolactone monotherapy (100mg daily, can be increased up to 400mg) 1
• For recurrent severe ascites or when faster diuresis is needed, use combination therapy with spironolactone (100-400mg) and furosemide (40-160mg) 1
• The goal of diuretic therapy is to ensure urinary sodium excretion exceeds 78 mmol/day 1
• Monitor response using spot urine sodium:potassium ratio; a ratio between 1.8-2.5 predicts adequate sodium excretion 1

Monitoring and Dose Adjustments

• Monitor for adverse events - almost half of patients require diuretic discontinuation or dose reduction due to complications 1
• Target weight loss of 0.5kg/day in patients without edema and up to 1kg/day in those with edema 1
• For patients with cirrhosis, initiate therapy in a hospital setting and titrate slowly 1, 2

Management of Hyponatremia

• Hypovolaemic hyponatremia (from excessive diuresis): discontinue diuretics and expand plasma volume with normal saline 1
• Hypervolaemic hyponatremia (more common): restrict fluid to 1-1.5 L/day only if serum sodium <125 mmol/L 1
• Hypertonic sodium chloride (3%) should be reserved for severely symptomatic patients with acute hyponatremia 1
• Serum sodium correction should be slow to prevent central pontine myelinolysis 1

Large Volume Paracentesis (LVP)

• Indicated for tense ascites as initial therapy, followed by sodium restriction and diuretics 1
• Ultrasound guidance should be considered during LVP to reduce adverse events 1
• Albumin (20% or 25% solution) should be infused after paracentesis of >5L at a dose of 8g albumin/L of ascites removed 1
• For paracentesis <5L, albumin can be considered in patients with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury 1

Management of Refractory Ascites

• Defined as ascites unresponsive to sodium restriction and high-dose diuretics (400mg spironolactone and 160mg furosemide) or when complications prevent use of effective doses 1
• Treatment options include serial therapeutic paracentesis, transjugular intrahepatic portosystemic shunt (TIPSS), or liver transplantation 1, 3
• TIPSS should be considered in patients with refractory ascites who have relatively preserved liver function 1
• Caution is required if considering TIPSS in patients with age >70 years, serum bilirubin >50 μmol/L, platelet count <75×109/L, MELD score ≥18, current hepatic encephalopathy, active infection or hepatorenal syndrome 1
• Midodrine (an α-adrenergic agonist) may be considered on a case-by-case basis for refractory ascites 1

Special Considerations

• Patients with spontaneous bacterial peritonitis (SBP) and increased or rising serum creatinine should receive albumin infusion (1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3) 1
• Liver transplantation should be considered in all patients with cirrhosis and ascites 1, 3
• Avoid NSAIDs as they can reduce urinary sodium excretion and convert diuretic-sensitive patients to refractory ones 1