What is the best treatment approach for a patient with cirrhosis and ascites?

Management of Cirrhosis with Ascites

For first-presentation moderate ascites, initiate spironolactone 100 mg daily with sodium restriction to 5-6.5 g/day, escalating spironolactone to 400 mg/day before adding furosemide; for recurrent or severe ascites, start combination therapy with spironolactone 100 mg plus furosemide 40 mg daily from the outset. 1

Initial Diagnostic Workup

• Perform diagnostic paracentesis on all cirrhotic patients with ascites at hospital admission to rule out spontaneous bacterial peritonitis and characterize the fluid 2
• Measure serum ascites-albumin gradient (SAAG) rather than ascitic protein as the primary diagnostic test 2
• Inoculate ascitic fluid into blood culture bottles at bedside and obtain neutrophil count 2

Treatment Algorithm Based on Ascites Severity

First-Presentation Moderate Ascites (Sequential Approach)

• Start with spironolactone monotherapy at 100 mg daily, increasing by 100 mg every 7 days up to maximum 400 mg/day if inadequate response 1, 2
• Restrict dietary sodium to 5-6.5 g/day (90 mmol/day) - a "no added salt" diet 1, 2
• Add furosemide 40 mg daily only if spironolactone alone fails, titrating up to 160 mg/day as needed 1, 2
• Bed rest is not recommended and provides no benefit 1, 2

Rationale for sequential approach in first-presentation ascites: While combination therapy may achieve faster ascites resolution, the sequential approach starting with spironolactone alone requires significantly fewer dose reductions (34% vs 68%) and allows better tolerance 1. Spironolactone has greater natriuretic potency than loop diuretics in cirrhotic patients with marked sodium retention 3, 4.

Recurrent or Severe Ascites (Combination Approach)

• Initiate combination therapy immediately with spironolactone 100 mg plus furosemide 40 mg daily 1, 2
• Escalate both medications proportionally up to maximum doses (spironolactone 400 mg, furosemide 160 mg) 1
• Maintain the 100:40 mg ratio of spironolactone to furosemide to preserve normokalemia 2

Rationale for combination approach in recurrent ascites: Patients with prior ascites benefit from upfront combination therapy, showing shorter time to resolution (76% vs 56% without dose changes), lower treatment failure rates (24% vs 44%), and reduced risk of adverse events, particularly hyperkalemia 1.

Monitoring Parameters and Target Response

• Target weight loss of 0.5 kg/day in patients without peripheral edema; 1 kg/day with edema 1, 2
• Monitor spot urine sodium:potassium ratio, targeting 1.8-2.5 to predict adequate 24-hour urinary sodium excretion >78 mmol/day 1
• Check serum electrolytes, creatinine, and clinical status regularly 1, 2
• Once ascites resolves, reduce diuretics to the lowest effective maintenance dose 1

Management of Hyponatremia During Treatment

Mild Hyponatremia (Serum Na 126-135 mmol/L, Normal Creatinine)

• Continue diuretic therapy with close electrolyte monitoring 1, 2
• Do not restrict fluids at this level 1

Moderate Hyponatremia (Serum Na 121-125 mmol/L, Normal Creatinine)

• Stop or significantly reduce diuretics - this represents a more cautious approach than international consensus 1, 2
• Reassess volume status before proceeding 1

Moderate Hyponatremia with Renal Impairment (Serum Na 121-125 mmol/L, Creatinine >150 μmol/L or rising)

• Immediately discontinue all diuretics 1, 2
• Provide volume expansion with colloid or normal saline 1
• This represents hypovolemic hyponatremia from overzealous diuresis 1

Severe Hyponatremia (Serum Na <120-125 mmol/L)

• Stop all diuretics immediately 1, 2
• Consider volume expansion with colloid (haemaccel, gelofusine, voluven) or saline 1, 2
• Avoid increasing serum sodium by >12 mmol/L per 24 hours to prevent osmotic demyelination 1
• Fluid restriction (1-1.5 L/day) has limited efficacy and should be reserved only for clinically hypervolemic patients 1

Critical caveat: Sodium restriction, not fluid restriction, drives weight loss as fluid passively follows sodium; fluid restriction to <1 L/day is poorly tolerated and rarely improves hyponatremia 1.

Additional Safety Considerations

• Temporarily discontinue diuretics for: serum sodium <125 mmol/L, worsening hypokalemia, hyperkalemia, rising creatinine, hepatic encephalopathy, or severe muscle cramps 1
• Initiate diuretic therapy in hospitalized patients with hepatic cirrhosis and ascites due to risk of precipitating hepatic coma with sudden fluid/electrolyte shifts 5, 6
• Supplement with potassium chloride and consider aldosterone antagonists to prevent hypokalemia and metabolic alkalosis 5
• Hyponatremia is associated with higher rates of refractory ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, hepatorenal syndrome, and mortality 1

Large Volume or Refractory Ascites

• Therapeutic paracentesis is first-line treatment for tense ascites 1, 2
• For paracentesis <5 liters: administer 150-200 mL synthetic plasma expander (gelofusine or haemaccel) 1, 2
• For large volume paracentesis: give albumin 8 g per liter of ascites removed (approximately 100 mL of 20% albumin per 3 liters removed) 1, 2
• Continue diuretics after paracentesis to prevent reaccumulation 3, 4

Transplant Evaluation

• Consider liver transplantation in all patients who develop cirrhotic ascites, as this represents a critical landmark in disease progression 1, 2
• Development of ascites indicates significantly impaired survival even with adequate medical management 1