How is ascites managed in patients with cirrhosis?

Management of Ascites in Cirrhosis

First-line treatment of ascites in cirrhosis consists of sodium restriction (88 mmol/day or 2000 mg/day) and diuretics, specifically starting with spironolactone alone and adding furosemide if needed. 1, 2

Initial Approach to Ascites Management

• Start with dietary sodium restriction to 88-90 mmol/day (2000 mg/day), equivalent to a "no added salt" diet 1, 2
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 1, 2
• Begin spironolactone at 100 mg/day as first-line diuretic therapy, increasing gradually to a maximum of 400 mg/day 1, 2
• Add furosemide (40 mg/day initially) only if spironolactone alone at maximum dose proves ineffective, with careful monitoring of electrolytes and renal function 1, 2
• Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide 1, 2

Management of Tense Ascites

• For patients with tense ascites, perform an initial therapeutic abdominal paracentesis followed by sodium restriction and oral diuretics 1, 2
• Large-volume paracentesis (LVP) removes fluid more rapidly (minutes) than diuresis (days to weeks) 1
• When performing LVP of >5L, administer albumin (8g/L of ascites removed) to prevent post-paracentesis circulatory dysfunction 1, 3
• Following paracentesis, diuretic therapy should be initiated or continued to prevent reaccumulation of ascites 1

Monitoring and Follow-up

• Monitor serum electrolytes, creatinine, and weight regularly during diuretic therapy 1, 2
• Patients may require evaluation every 2-4 weeks initially until response to treatment is established 1, 2
• Measure 24-hour urinary sodium excretion if weight loss is less than desired to assess dietary compliance 1, 2
• Watch for complications of diuretic therapy including hyponatremia, renal impairment, and hepatic encephalopathy 1

Management of Refractory Ascites

• Refractory ascites is defined as fluid overload unresponsive to sodium restriction and high-dose diuretics (400 mg/day spironolactone and 160 mg/day furosemide) 1
• Options for refractory ascites include:
  • Serial large-volume paracentesis with albumin replacement (8g/L of ascites removed) 1, 3
  • Transjugular intrahepatic portosystemic shunt (TIPSS) in selected patients 1, 4
• TIPSS should be considered carefully, with caution 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

Important Considerations and Pitfalls

• Avoid nonsteroidal anti-inflammatory drugs as they reduce urinary sodium excretion and can induce azotemia 1, 2
• Over-diuresis can lead to intravascular volume depletion (25%), renal impairment, hepatic encephalopathy (26%), and hyponatremia (28%) 1
• Non-compliance with dietary sodium restriction is a common cause of treatment failure 1, 2
• Consider liver transplantation for all patients with cirrhosis and ascites, as it offers a definitive cure 1, 2, 4
• Development of ascites indicates poor prognosis - approximately 20% of patients die within the first year of diagnosis 2, 3

Special Circumstances

• For hepatic hydrothorax, TIPSS should be considered after discussion with a multidisciplinary team 1
• Non-selective beta-blockers should not be automatically discontinued in patients with refractory ascites, but dose reduction or discontinuation may be appropriate in those who develop hypotension or progressive renal dysfunction 1
• For patients not eligible for liver transplantation or TIPSS with refractory ascites, palliative care referral should be considered 1, 4