What are the guidelines for ascitic fluid drainage in patients with Chronic Liver Disease (CLD) and recurrent ascites?

From the Guidelines

For patients with chronic liver disease (CLD) and recurrent ascites, large-volume paracentesis (LVP) plus albumin administration is recommended as the first-line treatment, with consideration of transjugular intrahepatic portosystemic shunt (TIPS) placement in suitable candidates for very frequent recurrences. The procedure should be performed by removing 4-6 liters of ascitic fluid at a time, with intravenous albumin administration (6-8 g per liter of fluid removed) when more than 5 liters are drained to prevent post-paracentesis circulatory dysfunction, as recommended by the EASL clinical practice guidelines 1.

Key Considerations

• Diuretic therapy with spironolactone and furosemide should be maintained between paracenteses, with doses adjusted based on response and sodium restriction advised, as suggested by the American Association for the Study of Liver Diseases guidance statements 1.
• Regular monitoring of renal function, electrolytes, and nutritional status is essential, with consideration of protein supplementation (1.2-1.5 g/kg/day) and salt restriction (5 g/day or less) in patients with cirrhotic ascites, as recommended by the KASL clinical practice guidelines 1.
• The use of small-diameter PTFE-covered stents in patients undergoing TIPS insertion is recommended to reduce the risk of TIPS dysfunction and hepatic encephalopathy, as stated in the EASL clinical practice guidelines 1.

Management Approach

• Patients with refractory or recurrent ascites should be evaluated for TIPS insertion, with careful selection of patients and consideration of the experience of the center performing the procedure, as recommended by the EASL clinical practice guidelines 1.
• Diuretics and salt restriction should be continued after TIPS insertion up to the resolution of ascites, along with close clinical follow-up, as suggested by the EASL clinical practice guidelines 1.
• The underlying mechanism of ascites in CLD involves portal hypertension, hypoalbuminemia, and sodium retention, making both fluid removal and prevention of reaccumulation important components of management.

From the Research

Guidelines for Ascitic Fluid Drainage

• The management of cirrhotic ascites includes dietary sodium restriction, diuretics, and large-volume paracentesis 2, 3, 4, 5.
• Sodium should be restricted to a maximum of 2 mEq/kg/d (max 90 mEq/d) of sodium/day 2.
• Oral diuretic therapy comprises aldosterone antagonists (e.g., spironolactone) with or without loop-diuretics (e.g., furosemide) 2, 3.
• Tense ascites should be managed with large-volume paracentesis (LVP) preferably with albumin infusion 2, 3, 4.
• Therapeutic options for refractory ascites include recurrent LVP, transjugular intrahepatic porto-systemic shunt, and liver transplantation 2, 3, 4, 5.

Complications of Ascitic Fluid Drainage

• Ascitic fluid infection (AFI) is an important complication and requires prompt antibiotic therapy 2, 3, 4.
• Other complications include hyponatremia, acute kidney injury, hepatic hydrothorax, and hernias 2.
• Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and has a risk of mortality of 20% 3.

Alternative Therapies

• Peritoneal dialysis (PD) can be considered a viable dialysis option in kidney failure patients with ascites, as it provides hemodynamic stability and facilitates better volume management compared to hemodialysis 6.
• PD obviates the need for therapeutic paracentesis by facilitating continuous drainage of ascites and potentially reduces hemorrhagic complications by avoiding routine anticoagulation use 6.