Diuresis Management in Liver Cirrhosis
Initiate combination therapy with oral spironolactone 100 mg plus furosemide 40 mg once daily in the morning for patients with Grade 2 or 3 ascites, while restricting sodium intake to less than 5 g/day (2 g sodium/88 mmol daily). 1
Grading Ascites and Treatment Approach
Grade 1 (Mild - Ultrasound Only):
- Sodium restriction alone (no diuretics needed) 1
- Treat underlying liver disease and provide nutritional education 1
- Discontinue NSAIDs, ACE inhibitors, and angiotensin receptor blockers 1
Grade 2 (Moderate Distension) and Grade 3 (Marked Distension):
- Sodium restriction PLUS diuretics required 1
- For Grade 3, add large-volume paracentesis with albumin (6-8 g per liter removed) 2, 3
Diuretic Regimen
Starting Doses:
- Spironolactone 100 mg + furosemide 40 mg as single morning oral doses 1, 3
- This combination achieves faster ascites control and maintains normokalemia better than monotherapy 1, 3
- Never use intravenous diuretics - oral administration is standard because IV use causes sudden fluid loss leading to kidney damage 1, 4
Dose Titration:
- Increase both drugs simultaneously every 3-5 days maintaining the 100:40 mg ratio if weight loss inadequate 1, 3
- Maximum doses: spironolactone 400 mg/day and furosemide 160 mg/day 1, 3
- For cirrhotic patients, initiate therapy in hospital setting and titrate slowly per FDA labeling 5
Alternative Sequential Approach (Outpatient Setting):
- Start spironolactone 50-100 mg monotherapy, add furosemide only if inadequate response after 3-4 days 1
- This slower approach may be useful for stable outpatients but delays ascites resolution 1
Critical Monitoring Parameters
Frequency:
- Check weight, serum sodium, potassium, and creatinine every 3-5 days initially 1, 3
- Then weekly for the first month 2
Target Weight Loss:
Sodium Restriction
- Restrict to less than 5 g salt/day (2 g sodium/88 mmol daily) 1
- Do not restrict more severely - excessive restriction worsens malnutrition 1
- Fluid restriction is NOT necessary unless severe hyponatremia (sodium <120-125 mmol/L) develops 1
Managing Complications
Hyperkalemia (K+ >5.5 mmol/L):
- Stop spironolactone immediately 2, 6
- Continue furosemide monotherapy 2, 6
- Consider amiloride 10-40 mg/day (1/10 dose of spironolactone) as alternative if spironolactone needs to be restarted 1
Hypokalemia:
Severe Hyponatremia (<125 mmol/L):
- Reduce or discontinue furosemide 2
- Institute fluid restriction to 1000 mL/day 2
- Avoid rapid correction with hypertonic saline - causes more complications than hyponatremia itself 1
Hepatic Encephalopathy:
- Discontinue all diuretics temporarily until mental status improves 3, 6
- Sudden fluid/electrolyte shifts can precipitate hepatic coma 4
Acute Kidney Injury or Worsening Azotemia:
Refractory Ascites Recognition
Definition: Ascites unresponsive to maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg daily for ≥1 week) OR development of complications preventing effective diuretic dosing 2
Management:
- Perform serial large-volume paracentesis with albumin replacement 2, 3
- Refer for liver transplantation evaluation - refractory ascites indicates poor prognosis 2, 3
Common Pitfalls to Avoid
- Never use loop diuretics as monotherapy - less efficacious than spironolactone due to secondary hyperaldosteronism 1
- Avoid excessive bed rest - no controlled trials support this, and it causes muscle atrophy 1
- Do not use IV furosemide routinely - associated with acute GFR reductions 1, 4
- Avoid NSAIDs, ACE inhibitors, and ARBs - these worsen ascites and cause hypotension 1, 3
Nutritional Support
- Provide 35-40 kcal/kg/day, protein 1.2-1.5 g/kg/day, carbohydrate 2-3 g/kg/day 1
- Add late-evening snack of 200 kcal to improve nutritional status 1
- Consider zinc supplementation - improves ascites and encephalopathy 1
Hospitalization Indications
Admit patients with ascites complicated by: 1
- Upper gastrointestinal bleeding
- Hepatic encephalopathy
- Bacterial infection
- Hypotension
- Hepatocellular carcinoma