What is the relationship between ascites and liver cirrhosis (cirrhosis)?

From the Guidelines

The management of ascites in cirrhosis should prioritize liver transplantation as the definitive treatment in appropriate candidates, given its significant impact on morbidity, mortality, and quality of life. Ascites is a common complication of cirrhosis, characterized by the accumulation of fluid in the abdominal cavity due to portal hypertension and decreased albumin production by the damaged liver. The development of ascites is associated with a mortality of 50% within two years of diagnosis 1. Management of ascites in cirrhosis begins with sodium restriction (2000mg/day) and diuretic therapy, typically starting with spironolactone 100mg daily and furosemide 40mg daily, as recommended by the European Association for the Study of the Liver 1. These doses can be gradually increased to maximum doses of spironolactone 400mg and furosemide 160mg daily while monitoring for complications like hyponatremia, hypokalemia, or renal dysfunction. For patients with moderate to severe ascites not responding to medical therapy, large volume paracentesis (LVP) may be necessary, with albumin replacement (6-8g per liter of fluid removed) for volumes greater than 5 liters to prevent circulatory dysfunction. Refractory ascites may require consideration of transjugular intrahepatic portosystemic shunt (TIPS) placement or evaluation for liver transplantation. Patients should be monitored for spontaneous bacterial peritonitis, a serious infection of ascitic fluid, which presents with fever, abdominal pain, or altered mental status and requires prompt antibiotic treatment. Regular weight monitoring and abdominal circumference measurements can help assess fluid status and treatment effectiveness.

Key considerations in the management of ascites include:

• Sodium restriction and diuretic therapy as the mainstays of treatment 1
• Monitoring for complications such as hyponatremia, hypokalemia, or renal dysfunction
• Large volume paracentesis (LVP) with albumin replacement for volumes greater than 5 liters
• Consideration of TIPS placement or liver transplantation for refractory ascites
• Monitoring for spontaneous bacterial peritonitis and prompt antibiotic treatment when necessary. The most recent and highest quality study 1 provides a clear rationale for the management of ascites in patients with cirrhosis, emphasizing the importance of liver transplantation as the definitive treatment in appropriate candidates.

From the Research

Ascites and Cirrhosis

• Ascites is the most common complication of cirrhosis, accounting for almost 85% of all cases 2.
• The development of ascites in cirrhotic patients is associated with a poor prognosis, with only 50% of patients surviving for 2 to 5 years after its development 2.
• The management of ascites is based on symptomatic measures, including restriction of sodium intake, diuretics, and paracentesis, as well as treatment of the underlying liver disease 3.

Treatment of Ascites

• The mainstay of treatment for ascites is restriction of sodium intake and enhancement of sodium excretion, which can be achieved through the use of oral diuretics such as spironolactone and furosemide 2.
• Patients with cirrhosis and ascites should limit their sodium intake to 2 grams per day, and the recommended initial dose of spironolactone is 100-200 mg/d and furosemide is 20-40 mg/d 2.
• About 90% of patients respond well to medical therapy for ascites, but refractory ascites is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment 2.

Refractory Ascites

• Refractory ascites has a poor prognosis and treatment options include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), or peritoneovenous shunt, and liver transplantation 2.
• TIPS should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver function 2, 4.
• Liver transplantation is the only modality that is associated with improved survival in patients with refractory ascites 2, 5.

New Therapies for Ascites

• Repeated albumin infusions and Alfapump have emerged as new therapies for ascites, although more research is needed to fully understand their effectiveness and safety 3, 5.
• Vasoconstrictors, vasopressin V(2) receptor antagonists, and peritoneo-vesical shunt are also being explored as potential new treatment options for ascites 4, 5.