What is the initial management for a patient with cirrhosis?

Initial Management of Cirrhosis

The initial management of cirrhosis centers on identifying and treating the underlying cause, implementing dietary sodium restriction to 88 mmol/day (2000 mg/day), and initiating diuretic therapy with spironolactone 100 mg daily (adding furosemide 40 mg if needed) for patients with ascites. 1, 2

Identify and Address the Underlying Cause

This is the most critical first step, as early cirrhosis may be reversible and treatment can prevent decompensation even in advanced disease 3, 4:

• Alcohol-related cirrhosis: Complete abstinence is essential and can lead to dramatic improvement or even "re-compensation" in some patients 1, 2
• Viral hepatitis: Initiate antiviral therapy immediately—for HBV use entecavir or tenofovir as first-line agents; for HCV use direct-acting antivirals 1, 2
• Metabolic/autoimmune causes: Address nonalcoholic fatty liver disease, autoimmune hepatitis, or other reversible factors 1

The effectiveness of treating the underlying cause varies based on disease severity at intervention, but this remains the cornerstone of preventing progression 3, 2.

Dietary Management

• Sodium restriction to 88 mmol/day (2000 mg/day), equivalent to a "no added salt" diet, is the foundation of ascites management 1, 5
• Protein intake of 1.2-1.5 g/kg/day to prevent malnutrition and sarcopenia 1
• Total caloric intake of 35-40 kcal/kg/day with 2-3 g/kg/day carbohydrates 1, 5
• Fluid restriction is NOT necessary unless serum sodium drops below 120-125 mmol/L 1, 2, 5

More aggressive sodium restriction beyond 88 mmol/day is not recommended as it may worsen malnutrition 2.

Pharmacological Management for Ascites

Start spironolactone 100 mg once daily as initial therapy 1, 5, 6:

• Add furosemide 40 mg once daily if response is inadequate after 3-5 days 1, 5
• Increase both medications simultaneously every 3-5 days (maintaining 100:40 mg ratio) if weight loss and natriuresis remain inadequate 5
• Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 1, 5
• In hospitalized patients with cirrhosis and ascites, initiate therapy in the hospital setting and titrate slowly due to risk of sudden electrolyte shifts that can precipitate hepatic encephalopathy 6

Management of Tense Ascites

• Perform therapeutic paracentesis first, followed by sodium restriction and diuretic therapy 1, 2
• For large-volume paracentesis (>5L), administer albumin at 8g per liter of ascites removed to prevent circulatory dysfunction 1, 5
• Delaying paracentesis in patients with tense ascites is a common and dangerous pitfall 1

Critical Medications to Avoid

• NSAIDs are absolutely contraindicated—they reduce urinary sodium excretion, can induce azotemia, and convert diuretic-sensitive ascites to refractory ascites 1, 2, 5
• Discontinue ACE inhibitors and angiotensin receptor blockers 2
• Avoid nephrotoxic agents of any kind 2

Monitoring Requirements

• Monitor serum electrolytes, creatinine, and weight regularly (initially every 2-4 weeks) 1, 5
• Measure 24-hour urinary sodium excretion if weight loss is inadequate—this helps distinguish dietary non-compliance from true diuretic resistance 1, 5
• Perform diagnostic paracentesis without delay on hospital admission to rule out spontaneous bacterial peritonitis (ascitic neutrophil count >250/mm³) 2

Transplant Evaluation

Consider liver transplantation evaluation for all patients with cirrhosis and ascites, as development of ascites carries a 20% one-year mortality 1, 5. Transplantation offers definitive cure for cirrhosis and its complications 1.

Gastroenterology Referral

Refer to gastroenterology when patients develop 2:

• Any decompensation event (ascites, variceal bleeding, hepatic encephalopathy)
• Refractory ascites requiring paracentesis more frequently than every 2 weeks
• Need for TIPS evaluation

Common Pitfalls to Avoid

• Inadequate sodium restriction due to poor dietary compliance is the most common cause of treatment failure 1
• Excessive bed rest—patients should remain active to prevent muscle atrophy and can be managed outpatient unless complicated by bleeding, encephalopathy, infection, or hypotension 2
• Overly aggressive diuresis leading to electrolyte abnormalities or acute kidney injury 1
• Failure to recognize spontaneous bacterial peritonitis, which requires immediate empirical antibiotics 2