What is the management approach for different grades of ascites?

Management of Ascites by Grade

The management of ascites in cirrhosis is stratified by severity: Grade 1 (mild) ascites requires no specific treatment; Grade 2 (moderate) ascites is managed with sodium restriction (80-120 mmol/day) and diuretics starting with spironolactone 100 mg/day with or without furosemide 40 mg/day; and Grade 3 (large/tense) ascites requires large-volume paracentesis with albumin infusion (8 g per liter removed) followed by diuretic therapy. 1

Diagnostic Approach

All patients with new-onset ascites require diagnostic paracentesis to establish etiology and exclude infection. 1

Essential initial tests include:

• Ascitic fluid neutrophil count (>250 cells/µL indicates spontaneous bacterial peritonitis) 1
• Serum-ascites albumin gradient (SAAG): SAAG ≥1.1 g/dL indicates portal hypertension with 97% accuracy 1
• Ascitic fluid total protein and albumin 1
• Ascitic fluid culture using bedside inoculation of blood culture bottles 1

Grade 1 (Mild) Ascites

Grade 1 ascites is only detectable by ultrasound and does not require specific treatment. 1 No evidence supports prophylactic salt restriction or diuretic therapy at this stage. 1

Grade 2 (Moderate) Ascites

First-line therapy combines moderate sodium restriction with diuretic therapy. 1

Sodium Restriction

• Limit sodium intake to 80-120 mmol/day (approximately 2 g or 4.6-6.9 g of salt), equivalent to a no-added-salt diet avoiding pre-prepared meals 1
• Fluid restriction is unnecessary unless serum sodium drops below 120-125 mmol/L 1
• Extreme sodium restriction risks malnutrition and should be avoided 1

Diuretic Therapy

Initial diuretic regimen:

• Start spironolactone 100 mg/day as monotherapy for first-episode ascites 1
• For long-standing or recurrent ascites, initiate combination therapy: spironolactone 100 mg/day plus furosemide 40 mg/day 1

Dose titration:

• Increase doses sequentially every 3-5 days (minimum 72 hours) based on response 1
• Maximum doses: spironolactone 400 mg/day, furosemide 160 mg/day 1
• The 100:40 mg ratio of spironolactone to furosemide helps maintain potassium balance 2
• Target weight loss: 0.5 kg/day without edema, 1 kg/day with peripheral edema 1

Monitoring requirements:

• Frequent clinical and biochemical monitoring during the first month, then every 2-4 weeks 1, 3
• Monitor weight, serum sodium, potassium, and creatinine 1, 2
• Spot urine sodium/potassium ratio >1 indicates adequate natriuresis; if ≤1, increase diuretics 1

Critical Safety Parameters

Discontinue ALL diuretics if: 1

• Severe hyponatremia (serum sodium <120-125 mmol/L)
• Progressive renal failure or acute kidney injury
• Worsening hepatic encephalopathy
• Incapacitating muscle cramps

Discontinue furosemide specifically if:

• Severe hypokalemia (<3 mmol/L) 1

Discontinue spironolactone specifically if:

• Severe hyperkalemia (>6 mmol/L) 1

Important caveats:

• Diuretics are generally contraindicated in patients with overt hepatic encephalopathy 1
• Correct serum potassium before starting diuretics 1
• Exercise caution in patients with baseline renal impairment or hyponatremia 1

Grade 3 (Large/Tense) Ascites

Large-volume paracentesis (LVP) with albumin infusion is the treatment of choice, NOT diuretics as initial therapy. 1

Large-Volume Paracentesis Protocol

LVP is superior to diuretics for Grade 3 ascites because it:

• More effectively and rapidly removes ascites 1
• Significantly shortens hospital stay 1
• Has lower rates of hyponatremia, renal impairment, and hepatic encephalopathy 1
• Carries extremely low risk of complications (hemorrhage 0.2-2.2%) even with INR >1.5 and platelets <50,000/µL 1, 3

Albumin administration is mandatory:

• Infuse 8 g of 20% albumin per liter of ascites removed 1
• Albumin is superior to all other plasma expanders (dextran-70, polygeline, saline) in preventing post-paracentesis circulatory dysfunction (PPCD) and reducing mortality 1
• For volumes <5 L, alternative expanders may be considered, but albumin remains preferred 1

Post-paracentesis circulatory dysfunction (PPCD) occurs in approximately 20% of patients without albumin and leads to: 1

• Rapid re-accumulation of ascites
• Hepatorenal syndrome
• Dilutional hyponatremia
• Shortened survival

Post-LVP Management

After initial LVP, start sodium restriction and diuretics as described for Grade 2 ascites to prevent or delay recurrence. 1 This combination approach reduces the need for repeated paracentesis. 1

Refractory Ascites

Refractory ascites is defined as ascites unresponsive to maximum diuretic doses (spironolactone 400 mg/day plus furosemide 160 mg/day) with sodium restriction, or ascites that recurs rapidly after LVP. 2

Management options include:

• Serial therapeutic paracenteses with albumin 2
• Transjugular intrahepatic portosystemic shunt (TIPS) 2
• Liver transplantation should be considered for all patients with Grade 2 or 3 ascites given the poor prognosis (40% one-year mortality, 50% two-year mortality) 1

Adjunctive Therapies

For muscle cramps:

• Albumin infusion 20-40 g/week 1
• Baclofen 10 mg/day, increasing weekly by 10 mg/day up to 30 mg/day 1

For inadequate response to furosemide:

• Consider switching to torsemide or bumetanide 1

For painful gynecomastia from spironolactone:

• Switch to amiloride or eplerenone 1