What is the initial management for patients with liver cirrhosis and ascites?

Initial Management of Liver Cirrhosis with Ascites

For patients with cirrhosis and ascites, first-line treatment consists of moderate sodium restriction (2 g or 88 mmol/day) combined with oral diuretics—spironolactone with or without furosemide—except in cases of tense ascites where therapeutic paracentesis should be performed first, followed immediately by sodium restriction and diuretics. 1

Grade 2 (Moderate) Ascites

Dietary Management

• Restrict sodium intake to 88 mmol/day (2 g/day or approximately 5 g salt/day), which corresponds to a "no added salt" diet 1
• More severe restriction is not recommended as it worsens malnutrition that is already present in these patients 1
• Fluid restriction is NOT necessary unless serum sodium drops to ≤125 mmol/L 1
• Ensure adequate nutrition: 1.2-1.5 g/kg/day protein, 2-3 g/kg/day carbohydrate, and 35-40 kcal/kg/day total calories 1

Diuretic Therapy

• Start with spironolactone 50-100 mg once daily as the primary agent, since it directly antagonizes aldosterone which drives sodium retention in cirrhosis 1
• Add furosemide 20-40 mg once daily if spironolactone alone is insufficient, maintaining approximately a 100:40 mg ratio of spironolactone to furosemide 1
• Titrate doses upward simultaneously every 3-5 days until achieving adequate natriuresis and weight loss 1
• Maximum doses are 400 mg/day spironolactone and 160 mg/day furosemide 1

Target Weight Loss

• Aim for 0.5 kg/day weight loss in patients with ascites alone 1
• Aim for 1 kg/day weight loss in patients with both ascites and peripheral edema 1

Grade 3 (Tense) Ascites

Initial Intervention

• Perform therapeutic large-volume paracentesis (LVP) as first-line treatment to provide rapid symptom relief 1
• Administer 6-8 g of albumin intravenously per liter of ascites removed to prevent post-paracentesis circulatory dysfunction 1
• This albumin replacement is particularly important when removing >5 L of fluid 1

Post-Paracentesis Management

• Immediately initiate sodium restriction (88 mmol/day) and oral diuretics after the paracentesis 1
• Follow the same diuretic regimen as for Grade 2 ascites (spironolactone ± furosemide) 1

Monitoring Requirements

Laboratory Monitoring

• Monitor body weight, serum sodium, serum potassium, and serum creatinine regularly to assess response and detect adverse effects 1
• Check these parameters every 3-5 days initially when titrating diuretics 1
• Measure 24-hour urinary sodium excretion if weight loss is inadequate despite diuretics 1

Diuretic Dose Adjustments

• Reduce or stop loop diuretics if hypokalemia develops (K+ <3.5 mmol/L) 1
• Reduce or stop spironolactone if hyperkalemia develops (K+ >5.5 mmol/L) 1
• Reduce or stop diuretics if any of the following occur: 1
  • Severe hyponatremia (Na+ <120 mmol/L)
  • Acute kidney injury (creatinine rise ≥0.3 mg/dL in 48 hours)
  • Overt hepatic encephalopathy
  • Severe muscle cramps

Critical Medications to Avoid

• Absolutely avoid NSAIDs as they reduce urinary sodium excretion, can induce azotemia, and convert diuretic-sensitive ascites to refractory ascites 1
• Avoid ACE inhibitors and angiotensin receptor blockers in patients with cirrhosis and ascites 1
• Avoid aminoglycoside antibiotics whenever possible due to nephrotoxicity risk 1

Liver Transplantation Evaluation

• Refer all patients with Grade 2 or 3 ascites for liver transplantation evaluation as the development of ascites indicates poor prognosis with 50% mortality at 6 months for refractory ascites 1, 2
• Transplantation offers definitive cure for cirrhosis and its complications 2

Treatment of Underlying Liver Disease

• Ensure alcohol abstinence in patients with alcoholic liver disease, as this can lead to dramatic improvement 1
• Treat viral hepatitis (HBV with antivirals, HCV with direct-acting antivirals) as this can improve liver function and reduce ascites 1
• Consider baclofen 10 mg/day (increasing by 10 mg/week up to 30 mg/day) for alcohol craving in alcoholic cirrhosis 1

Common Pitfalls to Avoid

• Do not use serial paracenteses as first-line therapy in diuretic-sensitive patients—reserve this for refractory ascites 1
• Do not delay paracentesis in tense ascites waiting for diuretics to work, as this causes unnecessary patient suffering 1
• Do not restrict fluids routinely—only when sodium is ≤125 mmol/L 1
• Do not discharge patients with uncontrolled ascites without ensuring they understand sodium restriction and have close outpatient follow-up within 1 week 1