Initial Management of Cirrhosis
The first-line treatment for patients with cirrhosis consists of sodium restriction (88 mmol/day or 2000 mg/day) and oral diuretics (spironolactone and furosemide). 1
Identification and Removal of Causative Factors
- Abstinence from alcohol is essential for patients with alcoholic cirrhosis and can lead to dramatic improvement in the reversible component of liver disease 1, 2
- Treatment of underlying viral hepatitis (HBV, HCV) should be initiated as appropriate, though results may vary depending on disease severity 2
- Removal of other causative factors (autoimmune, metabolic disorders) should be pursued when possible 2
Dietary and Lifestyle Management
- Restrict sodium intake to 88 mmol/day (2000 mg/day), equivalent to a "no added salt" diet 1, 2
- Nutritional intake should include 1.2-1.5 g/kg/day protein, 2-3 g/kg/day carbohydrate, and 35-40 kcal/kg/day total calories 1
- Smaller, frequent meals with a late-evening 200 kcal snack may improve nutritional status 1
- Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 2, 1
Pharmacological Management
Diuretic Therapy
- Start with spironolactone 100 mg once daily as the initial dose 1, 3
- Add furosemide 40 mg once daily if needed 1
- Titrate doses every 3-5 days (maintaining 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, 2
- For patients with cirrhosis, initiate spironolactone therapy in a hospital setting and titrate slowly 3
Important Medication Considerations
- Avoid nonsteroidal anti-inflammatory drugs as they can reduce urinary sodium excretion and induce azotemia 1, 2
- Avoid nephrotoxic drugs, vasodilators, and other medications that may worsen renal function 2
- Consider starting at lower doses in patients with renal impairment 3
Management of Ascites
Initial Ascites Management
- For tense ascites, perform therapeutic abdominal paracentesis followed by sodium restriction and oral diuretics 2
- For large-volume paracentesis (>5L), administer albumin (8g/L of ascites removed) to prevent circulatory dysfunction 1, 2
- Diuretic-sensitive patients should be treated with sodium restriction and oral diuretics rather than serial paracenteses 2
Refractory Ascites
- Defined as fluid overload unresponsive to sodium-restricted diet and high-dose diuretics (400 mg/day spironolactone and 160 mg/day furosemide) or recurs rapidly after therapeutic paracentesis 2, 1
- Management options include serial therapeutic paracenteses (every 2-3 weeks), transjugular intrahepatic portosystemic stent-shunt (TIPS), or liver transplantation evaluation 1, 2
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
- Follow-up frequency depends on response to treatment and patient stability, but initially should be every 2-4 weeks 2
- For patients with acute kidney injury, close monitoring is essential with prompt intervention if renal function worsens 2
Liver Transplantation Evaluation
- Consider liver transplantation for all patients with cirrhosis and ascites 2, 1
- Development of ascites is associated with poor prognosis - 20% of patients die within the first year of diagnosis 1
- Transplantation offers a definitive cure for cirrhosis and its complications 1
Common Pitfalls to Avoid
- Delaying paracentesis in patients with tense ascites 2
- Inadequate sodium restriction (diet non-compliance is a common cause of treatment failure) 1
- Overly aggressive diuresis leading to electrolyte abnormalities or renal dysfunction 2
- Failure to recognize and treat spontaneous bacterial peritonitis, which requires prompt antibiotic therapy 2
- Using NSAIDs, which can precipitate renal failure in cirrhotic patients 1, 4
- Failure to consider alcohol abstinence as a primary intervention 1, 2