How do you manage edema in liver cirrhosis?

Management of Edema in Liver Cirrhosis

The cornerstone of managing edema in liver cirrhosis involves sodium restriction (5-6.5 g/day), spironolactone as first-line therapy (starting at 100 mg/day and titrating up to 400 mg/day), with furosemide added if needed (starting at 40 mg/day up to 160 mg/day), and therapeutic paracentesis with albumin replacement for refractory cases. 1, 2

Initial Approach

• Restrict sodium intake to 5-6.5 g/day (87-113 mmol sodium), which translates to a no-added salt diet with avoidance of precooked meals 1
• Provide nutritional counseling on sodium content in diet to improve adherence while maintaining adequate nutritional status 1, 2
• Ensure adequate protein intake (1.2-1.5 g/kg/day) to prevent malnutrition and maintain nutritional status 1, 2
• Fluid restriction is generally not necessary unless hyponatremia is present (serum sodium <125 mmol/L) 1

Diuretic Therapy Algorithm

First-line Treatment:

• Start with spironolactone 100 mg daily as monotherapy for first presentation of moderate ascites 1, 3
• Increase dose gradually in 100 mg increments every 7 days if needed, up to maximum 400 mg/day 1, 2

Second-line Treatment:

• If response is suboptimal, add furosemide 40 mg daily 1
• Increase furosemide gradually up to maximum 160 mg/day if needed 1
• The combination therapy is particularly recommended for recurrent severe ascites or when faster diuresis is needed 1, 2

Monitoring and Weight Control

• Monitor daily weight to assess diuretic efficacy 1
• Target weight loss of 0.5 kg/day in patients without peripheral edema 1
• In patients with peripheral edema, weight loss can be more aggressive but should be carefully monitored 1
• Check serum electrolytes, creatinine, and spot urine Na/K ratio regularly 1, 2
• A spot urine Na/K ratio >1 indicates adequate sodium excretion (>78 mmol/day) 1

Managing Complications

• Temporarily discontinue diuretics if any of the following develop 1:

  • Hyponatremia (serum sodium <125 mmol/L)
  • Acute kidney injury
  • Hepatic encephalopathy
  • Severe muscle cramps
  • Significant electrolyte imbalances

• For hypovolemic hyponatremia (due to excessive diuresis), discontinue diuretics and expand plasma volume with normal saline 1

• For hypervolemic hyponatremia, consider fluid restriction to 1-1.5 L/day only if serum sodium <125 mmol/L 1

• If hypokalemia occurs, reduce or stop furosemide 1

• If hyperkalemia develops, reduce or stop spironolactone 1

Management of Refractory Edema

• Refractory ascites is defined as ascites that cannot be mobilized despite maximum diuretic therapy (spironolactone 400 mg/day and furosemide 160 mg/day) and sodium restriction 1

Therapeutic Paracentesis:

• Large volume paracentesis (LVP) is effective for refractory ascites 1, 4
• Administer albumin (8 g per liter of ascites removed) after paracentesis of >5 L to prevent circulatory dysfunction 1
• Consider albumin administration even after paracentesis of <5 L in high-risk patients (those with acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury) 1

Advanced Options:

• Consider transjugular intrahepatic portosystemic shunt (TIPSS) in selected patients with refractory ascites 1, 4
• Liver transplantation should be considered as the definitive treatment for eligible patients with refractory ascites 5, 4

Common Pitfalls and Caveats

• Avoid extreme sodium restriction (<40 mmol/day) as it can worsen nutritional status and increase diuretic-induced complications 1
• Do not increase diuretic doses more frequently than every 72 hours, as the full effect of anti-mineralocorticoids takes time to develop 1
• Avoid rapid correction of hyponatremia (limit to 8-10 mmol/L per 24 hours) to prevent central pontine myelinolysis 1
• Routine measurement of prothrombin time and platelet count before therapeutic paracentesis is not recommended 1
• Vaptans are not recommended for routine management of ascites despite their effect on improving serum sodium concentration, due to concerns about increased mortality 1, 6