What is the role of diuretics, such as spironolactone (aldosterone antagonist) and furosemide (loop diuretic), in managing ascites in a patient with Spontaneous Bacterial Peritonitis (SBP) and cirrhosis, who also has a history of epilepsy and potential for impaired renal function?

Role of Diuretics in Spontaneous Bacterial Peritonitis

Diuretics should be continued during treatment of SBP in hemodynamically stable patients with cirrhosis and ascites, but must be temporarily discontinued if complications such as acute kidney injury, severe hyponatremia (<120-125 mmol/L), or worsening hepatic encephalopathy develop. 1

Diuretic Management During Active SBP

Continue Diuretics in Stable Patients

• Diuretics are not contraindicated during SBP treatment if the patient remains hemodynamically stable, has adequate renal function, and maintains electrolyte balance. 1
• The standard combination of spironolactone (100-400 mg/day) and furosemide (40-160 mg/day) should be maintained at the patient's established dose during antibiotic therapy for SBP, provided no complications arise. 1, 2
• Oral administration of furosemide is preferred over IV to avoid acute reductions in glomerular filtration rate. 2

Absolute Indications to Stop Diuretics During SBP

• Discontinue diuretics immediately if serum sodium drops below 120-125 mmol/L, as severe hyponatremia is an absolute contraindication. 1, 3
• Stop diuretics if serum creatinine increases by >0.3 mg/dL within 48 hours or rises to >2.0 mg/dL, indicating acute kidney injury. 1, 3
• Discontinue if serum potassium falls below 3 mmol/L or rises above 6 mmol/L despite appropriate measures. 1, 3
• Stop diuretics if worsening hepatic encephalopathy develops in the absence of other precipitating factors. 1, 3, 4
• Discontinue if marked hypovolemia, hypotension (systolic BP <90 mmHg), or anuria occurs. 1, 2

Monitoring Requirements During SBP Treatment

Critical Parameters to Track

• Check serum creatinine, sodium, and potassium within 3-5 days of SBP diagnosis and every 3-7 days during treatment. 1, 5
• Monitor daily weights with target weight loss not exceeding 0.5 kg/day in patients without peripheral edema, or 1.0 kg/day with peripheral edema. 1
• Assess blood pressure and signs of hypovolemia (decreased skin turgor, tachycardia) regularly. 1, 2

Hypovolemic Hyponatremia Management

• If hypovolemic hyponatremia develops during diuretic therapy, discontinue diuretics and expand plasma volume with normal saline. 1
• Fluid restriction to 1-1.5 L/day should be reserved only for those who are clinically hypervolemic with severe hyponatremia (serum sodium <125 mmol/L). 1
• Hypertonic sodium chloride (3%) administration should be reserved for severely symptomatic patients with acute hyponatremia, with slow correction of serum sodium. 1

Resuming Diuretics After SBP Resolution

Timing and Approach

• Once SBP is successfully treated (confirmed by repeat paracentesis showing ascitic neutrophil count <250 cells/mm³) and complications have resolved, diuretics should be restarted at the previous effective dose. 1
• Maintain the spironolactone-to-furosemide ratio of 100:40 mg to optimize natriuretic effect while minimizing electrolyte disturbances. 1, 5
• Resume with spironolactone 100 mg plus furosemide 40 mg as a single morning dose, then titrate every 3-5 days if needed. 1, 5

Post-SBP Prophylaxis Considerations

• Patients who recover from SBP should receive long-term antibiotic prophylaxis with norfloxacin 400 mg daily, ciprofloxacin 500 mg daily, or co-trimoxazole (800 mg sulfamethoxazole/160 mg trimethoprim daily). 1
• Continue diuretic therapy alongside antibiotic prophylaxis to prevent ascites reaccumulation, which increases risk of recurrent SBP. 1, 6

Common Pitfalls to Avoid

• Do not automatically discontinue diuretics in all SBP patients—only stop if specific complications develop. Premature discontinuation leads to rapid ascites reaccumulation. 1
• Avoid IV furosemide during SBP treatment, as it causes acute GFR reduction and worsens renal function in cirrhotic patients. 2, 3
• Do not use NSAIDs during SBP, as they impair diuretic response, reduce renal perfusion, and can precipitate acute kidney injury. 4, 7
• Never escalate diuretics beyond spironolactone 400 mg/day plus furosemide 160 mg/day—exceeding these doses indicates diuretic resistance requiring large-volume paracentesis instead. 1, 3

Special Considerations for Refractory Ascites

• If ascites becomes refractory during or after SBP (defined as failure to respond to maximum diuretic doses of spironolactone 400 mg/day plus furosemide 160 mg/day for at least one week on salt restriction <5 g/day), diuretics should generally be discontinued. 3
• Large-volume paracentesis with albumin replacement (6-8 g per liter removed) becomes first-line therapy for refractory ascites. 1, 3, 6
• Patients with refractory ascites should be immediately referred for liver transplant evaluation, as median survival is approximately 6 months. 3