What is the management approach for a palliative care patient with ascites?

Management of Palliative Care Patient with Ascites

For palliative care patients with ascites, large volume paracentesis (LVP) is the mainstay of symptomatic management, with consideration of long-term abdominal drains as an alternative palliative intervention to reduce hospital visits and improve quality of life. 1

Initial Assessment and Management

• Diagnostic paracentesis should be performed in all patients with new-onset ascites to determine etiology (cirrhotic vs. malignant) and rule out spontaneous bacterial peritonitis 1
• Sodium restriction (88 mmol/day or 2000 mg/day) should be implemented as a first-line dietary measure 1
• Diuretic therapy remains the cornerstone of initial medical management for patients with preserved renal function 1, 2

Diuretic Regimen

• Start with oral spironolactone 100 mg daily and furosemide 40 mg daily in a single morning dose 1
• Doses can be increased simultaneously every 3-5 days (maintaining 100:40 mg ratio) if weight loss is inadequate 1
• Maximum recommended doses are spironolactone 400 mg/day and furosemide 160 mg/day 1, 2
• For patients with minimal fluid overload, spironolactone alone may be sufficient and requires fewer dose adjustments 3
• Monitor for adverse effects including:
  • Hyperkalemia (especially with spironolactone) 4
  • Hyponatremia, hypovolemia, and renal dysfunction 4
  • Mental confusion and neurological impairment 4

Management of Refractory Ascites

Refractory ascites is defined as fluid overload unresponsive to sodium restriction and high-dose diuretics, or when maximal doses cannot be reached due to adverse effects 5

Large Volume Paracentesis (LVP)

• LVP is the primary palliative intervention for symptomatic relief in patients with refractory ascites 1
• Ultrasound guidance should be considered when available to reduce adverse events 1
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 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 at high risk of post-paracentesis acute kidney injury 1

Alternative Palliative Interventions

• Patients with refractory ascites who are not undergoing liver transplant evaluation should be offered a palliative care referral 1
• Long-term abdominal drains may be considered to prevent repeated hospital visits for paracentesis, though further research is needed 1
• Automated low-flow ascites pumps should only be considered in special circumstances with robust clinical governance 1

Special Considerations

Malignant Ascites

• Diuretics are effective in approximately one-third of patients with malignant ascites 6
• Paracentesis provides symptomatic relief in up to 90% of patients with malignant ascites 6
• Permanent percutaneous drains may be appropriate for end-stage patients to avoid repeated paracentesis, though infection risk exists 6

Transjugular Intrahepatic Portosystemic Shunt (TIPSS)

• TIPSS should be considered in selected patients with refractory ascites who have preserved liver function 1
• Caution is required if considering TIPSS 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

Monitoring and Follow-up

• Patients should be seen promptly in the outpatient setting after discharge, ideally within approximately 1 week 1
• Regular monitoring of electrolytes, renal function, and mental status is essential 4
• Weight loss targets: 300-500g/day in patients without peripheral edema; no limit for patients with edema 1
• Non-selective beta-blockers should be monitored closely in patients with refractory ascites, with dose reduction or discontinuation if hypotension or progressive renal dysfunction develops 1