What is the best management approach for a patient with symptomatic ascites, possibly due to liver disease, with consideration of diuretic therapy and dietary restrictions?

Management of Symptomatic Ascites in Cirrhosis

First-line treatment for symptomatic ascites due to cirrhosis consists of dietary sodium restriction to 5-6.5 g/day (87-113 mmol/day) combined with oral diuretics: spironolactone and furosemide. 1

Initial Assessment and Tense Ascites

• Patients presenting with tense (severe) ascites should undergo initial large-volume paracentesis (LVP) to provide rapid symptom relief, followed immediately by sodium restriction and oral diuretics. 1
• For LVP removing >5 liters, administer 6-8 g of intravenous albumin per liter of ascitic fluid removed to prevent post-paracentesis circulatory dysfunction. 1
• Ultrasound guidance should be considered when available to reduce adverse events during paracentesis. 1

Dietary Sodium Restriction

• All patients with ascites must restrict sodium intake to no more than 5-6.5 g/day (87-113 mmol sodium), which translates to a no-added-salt diet with avoidance of precooked meals. 1
• Patients should receive nutritional counseling on sodium content in their diet. 1
• Fluid restriction is NOT necessary unless serum sodium falls below 120-125 mmol/L. 1

Diuretic Therapy

First Presentation of Moderate Ascites

• Start with spironolactone monotherapy at 100 mg daily, which can be increased to a maximum of 400 mg/day. 1
• This approach is reasonable for patients with first presentation of moderate ascites who are not hospitalized. 1

Recurrent or Severe Ascites (or Hospitalized Patients)

• Begin combination therapy with spironolactone 100 mg plus furosemide 40 mg daily, maintaining the 100:40 ratio. 1
• This combination is recommended when faster diuresis is needed or for patients with recurrent severe ascites. 1

Dose Titration

• Increase both diuretics simultaneously every 3-5 days (maintaining the 100:40 ratio) if weight loss and natriuresis are inadequate. 1
• Maximum doses are spironolactone 400 mg/day and furosemide 160 mg/day. 1
• Single morning dosing maximizes patient compliance. 1
• The 100:40 ratio generally maintains normokalemia, though adjustments may be needed. 1

Target Weight Loss

• Aim for weight loss of 0.5 kg/day in patients without peripheral edema. 1
• In patients with peripheral edema, weight loss of up to 1 kg/day is acceptable. 1

Monitoring During Diuretic Therapy

• Monitor weight, vital signs, serum creatinine, sodium, and potassium levels regularly. 1
• A spot urine sodium:potassium ratio between 1.8-2.5 predicts adequate 24-hour urinary sodium excretion (>78 mmol/day) with 87.5% sensitivity. 1
• Almost half of patients on diuretics develop adverse events requiring dose reduction or discontinuation. 1

Managing Diuretic Complications

Temporarily discontinue or reduce diuretics if any of the following occur: 1

• Severe hyponatremia (serum sodium <125 mmol/L)
• Hypokalemia (<3 mmol/L) - temporarily withhold furosemide 1
• Hyperkalemia (>6 mmol/L) - reduce or stop spironolactone 1
• Acute kidney injury or serum creatinine >2.0 mg/dL 1
• Overt hepatic encephalopathy 1
• Severe muscle cramps 1

For hypovolemic hyponatremia: discontinue diuretics and expand plasma volume with normal saline. 1

For hypervolemic hyponatremia: fluid restriction to 1-1.5 L/day should be reserved only for severe hyponatremia (<125 mmol/L) with clinical hypervolemia. 1

Refractory Ascites

Refractory ascites is defined as fluid overload that either: 1

1. Fails to respond to sodium restriction and maximum-dose diuretics (spironolactone 400 mg/day plus furosemide 160 mg/day) for at least 1 week, OR
2. Recurs rapidly after therapeutic paracentesis

Additional criteria include: 1

• Mean weight loss <800 g over 4 days despite maximum therapy
• Urinary sodium output less than sodium intake
• Recurrence of grade 2-3 ascites within 4 weeks of initial mobilization

Management of Refractory Ascites

• Serial large-volume paracentesis with albumin replacement (6-8 g per liter removed) is the first-line treatment for refractory ascites. 1, 2
• Diuretics should generally be discontinued once refractoriness is established, unless urinary sodium excretion exceeds 30 mmol/day. 1, 2
• All patients with refractory ascites should be immediately referred for liver transplantation evaluation, as median survival is approximately 6 months. 2
• Transjugular intrahepatic portosystemic shunt (TIPS) should be considered for patients with preserved liver function who repeatedly fail large-volume paracentesis. 2, 3

Critical Pitfalls to Avoid

• Avoid nonsteroidal anti-inflammatory drugs (NSAIDs), as they reduce urinary sodium excretion and can convert diuretic-sensitive ascites to refractory ascites. 1, 2
• Avoid intravenous furosemide, as it causes acute reductions in glomerular filtration rate compared to oral administration. 1
• Do not perform serial paracenteses in diuretic-sensitive patients - they should be treated with sodium restriction and oral diuretics instead. 1
• Patients with parenchymal renal disease (e.g., diabetic nephropathy) may require less spironolactone due to hyperkalemia risk. 1
• Amiloride (10-40 mg/day) can be substituted for spironolactone if needed. 1

Liver Transplantation

Liver transplantation should be considered in all patients with cirrhosis and ascites, as it is the only treatment modality associated with improved survival. 1, 4