What is the best management approach for a patient with ascites due to liver disease, such as cirrhosis, considering potential complications like heart failure and kidney disease?

Management of Ascites in Cirrhosis

For patients with ascites due to cirrhosis, initiate management with dietary sodium restriction to 88 mmol/day (2000 mg/day) combined with oral diuretics—starting with spironolactone 100 mg daily, adding furosemide 40 mg daily as needed—while performing diagnostic paracentesis on all new-onset cases to rule out infection and confirm portal hypertension as the cause. 1, 2

Initial Diagnostic Evaluation

All patients with new-onset ascites require diagnostic paracentesis immediately to establish the etiology and exclude infection, which carries high mortality risk. 1, 3

• Essential ascitic fluid tests include: cell count with differential (to detect spontaneous bacterial peritonitis if neutrophils >250 cells/mm³), ascitic fluid albumin or total protein, and calculation of serum-ascites albumin gradient (SAAG). 1
• SAAG ≥1.1 g/dL indicates portal hypertension (cirrhosis, cardiac failure), while SAAG <1.1 g/dL suggests non-portal hypertension causes (malignancy, tuberculosis, pancreatitis). 1
• Inoculate ascitic fluid into blood culture bottles at the bedside before starting antibiotics if infection is suspected. 1
• Repeat diagnostic paracentesis at every hospital admission to rule out spontaneous bacterial peritonitis, as it carries high mortality and requires prompt treatment. 1

First-Line Medical Management

Dietary Sodium Restriction

Restrict sodium intake to 88 mmol/day (2000 mg/day), equivalent to approximately 5 grams of salt or one teaspoon, with no added salt at the table. 1, 2

• More stringent restriction can accelerate fluid mobilization but risks worsening malnutrition, which is already common in cirrhotic patients. 1, 2
• Fluid restriction is NOT necessary unless serum sodium falls below 120-125 mmol/L. 1, 2
• Weight loss correlates directly with sodium balance—it is sodium restriction, not fluid restriction, that drives diuresis. 1

Diuretic Therapy

Start with spironolactone 100 mg once daily as the initial diuretic, as secondary hyperaldosteronism is the primary driver of sodium retention in cirrhosis. 1, 2

• Add furosemide 40 mg once daily if spironolactone alone is insufficient or if hyperkalemia develops. 1, 2
• Maximum doses are 400 mg/day spironolactone and 160 mg/day furosemide, maintaining a ratio of approximately 100:40. 1, 2
• Monotherapy with loop diuretics alone is NOT recommended—aldosterone antagonists are the mainstay. 1
• Oral administration is standard; avoid intravenous diuretics as they can cause sudden fluid shifts leading to kidney damage. 1, 4

Monitoring During Diuretic Therapy

Monitor serum electrolytes, creatinine, and daily weights regularly to detect complications including hyponatremia, hyperkalemia, hypokalemia, and acute kidney injury. 1, 2, 3

• Measure 24-hour urinary sodium excretion if weight loss is inadequate—target >78 mmol/day to ensure adequate natriuresis. 1, 2
• Men should excrete >15 mg creatinine/kg/day and women >10 mg/kg/day to confirm complete 24-hour urine collection. 1

Management of Tense or Large-Volume Ascites

Perform large-volume paracentesis (>5 L) as first-line treatment for tense ascites to provide rapid symptom relief. 1, 2

• Administer intravenous albumin at 8 g per liter of ascites removed to prevent post-paracentesis circulatory dysfunction, which increases mortality. 1, 2, 5, 3
• For paracentesis <5 L, synthetic plasma expanders (150-200 mL gelofusine or haemaccel) may be used instead of albumin. 1
• For patients with hypotension, renal insufficiency, or electrolyte abnormalities, consider albumin even for smaller volume removals. 3
• After initial paracentesis, continue sodium restriction and diuretics to prevent reaccumulation. 1, 2

Management of Refractory Ascites

Refractory ascites is defined as fluid overload unresponsive to maximum-dose diuretics (400 mg/day spironolactone plus 160 mg/day furosemide) or rapid recurrence after therapeutic paracentesis. 1, 2

Treatment Options for Refractory Ascites:

1. Serial large-volume paracentesis every 2-3 weeks with albumin infusion remains the most common palliative approach. 1, 3

2. Transjugular intrahepatic portosystemic shunt (TIPS) is effective in reducing need for repeated drainage but requires careful patient selection. 1, 2

   • TIPS is contraindicated in advanced liver disease where it can precipitate hepatic encephalopathy or hasten death. 1
   • Well-selected patients with refractory ascites should be referred for TIPS evaluation. 3

3. Liver transplantation is the only curative option and should be considered for all patients with refractory ascites, regardless of MELD score. 1, 3

Critical Medications to AVOID

Nonsteroidal anti-inflammatory drugs (NSAIDs) must be avoided as they reduce urinary sodium excretion, induce azotemia, and can convert diuretic-sensitive patients to refractory status. 2, 6

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers should be discontinued as they worsen hypotension in cirrhotic patients. 1, 2, 6

Special Considerations for Alcoholic Liver Disease

Alcohol cessation is the single most effective intervention for alcoholic cirrhosis with ascites, with approximately 75% 3-year survival in abstinent patients versus 0% in those who continue drinking. 2

• Abstinence can result in dramatic improvement even in advanced disease, making ascites more responsive to medical therapy. 1, 2
• Patients with decompensated alcoholic cirrhosis should ideally initiate diuretic therapy in the hospital to allow close monitoring. 4

Management of Spontaneous Bacterial Peritonitis

If ascitic fluid neutrophil count >250 cells/mm³, start empiric antibiotics immediately before culture results. 1

• Third-generation cephalosporins (cefotaxime) are first-line therapy for spontaneous bacterial peritonitis. 1
• Administer albumin 1.5 g/kg within 6 hours, then 1 g/kg on day 3 to patients with spontaneous bacterial peritonitis and signs of renal impairment to prevent hepatorenal syndrome. 1
• After recovery from one episode, provide continuous prophylaxis with norfloxacin 400 mg/day (or ciprofloxacin 500 mg once daily) to prevent recurrence. 1

Prognosis and Transplant Evaluation

Development of ascites marks a critical milestone with approximately 20% mortality in the first year of diagnosis. 1

• All patients with ascites should be evaluated for liver transplantation, preferably before development of renal dysfunction. 1, 7, 3
• Refractory ascites carries 50% 6-month mortality without transplantation. 8

Common Pitfalls to Avoid

• Do not assume alcoholic patients have alcoholic liver disease—perform full diagnostic workup including paracentesis. 1
• Do not restrict fluids unless serum sodium <120-125 mmol/L—sodium restriction, not fluid restriction, drives diuresis. 1, 2
• Do not use bed rest as a management strategy—it lacks evidence and promotes muscle atrophy. 1
• Do not delay diagnostic paracentesis—infection must be ruled out promptly given high mortality risk. 1
• Do not use loop diuretics as monotherapy—aldosterone antagonists are essential. 1