What is the recommended treatment for patients with ascites suspected of having impaired renal function?

Management of Ascites with Suspected Renal Impairment

For patients with ascites suspected of having impaired renal function, diuretics should be temporarily discontinued and volume expansion with albumin or colloid solutions should be initiated to preserve renal function. 1

Initial Assessment and Management

• Immediately check serum creatinine, sodium, and potassium levels to determine the severity of renal impairment and electrolyte abnormalities 1
• Stop diuretics if serum creatinine is elevated (>150 μmol/L or >120 μmol/L and rising) to prevent further deterioration of renal function 1
• Monitor for signs of hepatorenal syndrome, which can develop in 14-20% of hospitalized patients with ascites treated with diuretics 1

Volume Expansion Strategy

• Administer intravenous albumin (recommended dose: 1g/kg body weight up to a maximum of 100g) to expand plasma volume and improve renal perfusion 1
• Alternative colloid solutions such as gelofusine or haemaccel can be used if albumin is not available 1
• Normal saline (0.9% NaCl) can be used for volume expansion but may worsen sodium retention in cirrhotic patients 1, 2
• Avoid increasing serum sodium by >12 mmol/L in 24 hours to prevent neurological complications, especially in patients with hyponatremia 1, 2

Management Based on Serum Sodium Levels

For patients with normal sodium (>135 mmol/L):

• After volume expansion and stabilization of renal function, cautiously reintroduce diuretics at lower doses 1
• Start with spironolactone 50-100 mg/day before adding furosemide 1, 3

For patients with mild hyponatremia (126-135 mmol/L):

• Continue diuretic therapy with careful monitoring of electrolytes if renal function is stable 1
• Do not restrict water intake 1

For patients with moderate hyponatremia (121-125 mmol/L):

• Stop diuretics if renal function is impaired 1
• Administer volume expansion with colloid or albumin 1
• Monitor serum sodium every 2-4 hours initially when correcting hyponatremia 2

For patients with severe hyponatremia (<120 mmol/L):

• Immediately discontinue all diuretics 1
• Administer volume expansion with colloid solutions or albumin 1
• Avoid rapid correction of hyponatremia (keep correction <12 mmol/L per 24 hours) 1, 2

Resuming Diuretic Therapy

• Only resume diuretics after renal function has improved and stabilized 1
• When restarting diuretics, begin with lower doses than previously used 1, 4
• Spironolactone is preferred as the initial agent due to its higher response rate (95%) compared to furosemide (52%) in non-azotemic patients 1, 5
• For patients who previously required combination therapy, consider starting with spironolactone alone before adding furosemide 5
• Monitor weight loss carefully: should not exceed 0.5 kg/day in patients without peripheral edema and 1 kg/day in patients with peripheral edema 1, 4

Monitoring During Treatment

• Check serum creatinine, sodium, and potassium frequently (every 1-3 days initially) 1
• Monitor urine sodium:potassium ratio to assess response to diuretics (target ratio between 1.8 and 2.5) 1
• Assess for signs of hepatic encephalopathy, which can occur in up to 25% of hospitalized patients treated with diuretics 1
• Regularly evaluate for other diuretic-related adverse effects including muscle cramps, gynecomastia, and hyperkalemia 6, 3

Management of Refractory Ascites

• For patients who develop diuretic resistance or intolerance, consider large volume paracentesis with albumin replacement (8g albumin per liter of ascites removed) 1
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for suitable candidates with preserved liver function who repeatedly fail large-volume paracentesis 1, 4
• Evaluate for liver transplantation, which is the only treatment associated with improved long-term survival 4