What are the EASL (European Association for the Study of the Liver) guidelines for managing ascites in patients with cirrhosis?

EASL Guidelines for Management of Ascites in Cirrhosis

The management of ascites in cirrhosis should follow a structured approach beginning with dietary salt restriction (5-6.5g/day) and diuretic therapy, progressing to large volume paracentesis with albumin replacement for refractory cases, and consideration of TIPSS for suitable candidates. 1

Initial Assessment and Classification

• Diagnostic paracentesis is recommended for all patients with new-onset grade 2-3 ascites or hospitalized patients with worsening ascites 1
• Ascitic fluid should be analyzed for neutrophil count, culture, total protein, and SAAG (serum-ascites albumin gradient) to determine etiology 1
• Ascites is classified as grade 1 (mild, only detectable by ultrasound), grade 2 (moderate, with symmetrical abdominal distension), or grade 3 (large or tense with marked distension) 1

First-Line Management

Dietary Sodium Restriction

• Patients should follow a moderately salt-restricted diet with daily intake of 5-6.5g salt (87-113 mmol sodium) 1, 2
• A "no added salt" diet with avoidance of precooked meals is recommended 1
• Nutritional counseling should be provided to educate patients on sodium content in foods 1

Diuretic Therapy

• For first presentation of moderate ascites: Start with spironolactone monotherapy (starting dose 100mg, increased to maximum 400mg) 1
• For recurrent or severe ascites: Use combination therapy with spironolactone (starting at 100mg, up to 400mg) and furosemide (starting at 40mg, up to 160mg) 1
• Diuretic doses should be increased every 7 days until adequate response is achieved 1
• Target weight loss should be 0.5 kg/day in patients without edema and 1 kg/day in those with edema 1

Management of Complications

Hyponatremia

• Hypovolaemic hyponatremia (due to excessive diuresis): Discontinue diuretics and expand plasma volume with normal saline 1
• Hypervolaemic hyponatremia: Fluid restriction (1-1.5 L/day) should be reserved only for patients with severe hyponatremia (serum sodium <125 mmol/L) 1, 2
• Hypertonic sodium chloride (3%) should be used only for severely symptomatic patients with acute hyponatremia 1

Refractory Ascites

Defined as ascites that cannot be mobilized despite:

• Maximum diuretic therapy (spironolactone 400mg/day and furosemide 160mg/day) for at least 1 week 1
• Salt restriction <5g/day 1
• Mean weight loss <800g over 4 days and urinary sodium output less than intake 1

Management options include:

1. Large Volume Paracentesis (LVP):

   • 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 ACLF or high risk of post-paracentesis AKI 1

2. Transjugular Intrahepatic Portosystemic Shunt (TIPSS):

   • Should be considered in patients with refractory ascites 1
   • Caution is required 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

3. Adjunctive Therapies:

   • Midodrine may be considered on a case-by-case basis for refractory ascites 1

Special Considerations

Spontaneous Bacterial Peritonitis (SBP)

• In patients with SBP and increased or rising serum creatinine, albumin infusion (1.5g/kg within 6 hours of diagnosis, followed by 1g/kg on day 3) is recommended 1

Liver Transplantation

• Development of ascites indicates poor prognosis and should prompt consideration for liver transplantation 1
• Liver transplantation is the ultimate treatment for ascites and its complications 1

Common Pitfalls to Avoid

• Extreme sodium restriction (<40 mmol/day) should be avoided as it may impair nutritional status 2
• Routine measurement of prothrombin time and platelet count before paracentesis is not recommended 1
• Bed rest is not recommended for the treatment of ascites 1
• Non-selective beta-blockers should be used with caution in patients with refractory ascites as they may worsen outcomes 1