What is the approach to managing ascites (accumulation of fluid in the peritoneal cavity)?

From the Guidelines

The approach to ascites involves a systematic evaluation and management strategy, starting with identifying the underlying cause and using diuretic therapy with spironolactone 100 mg daily, which can be increased to 400 mg daily if needed, and adding furosemide 40 mg daily if necessary, as recommended by the most recent guidelines 1. The diagnostic workup should include a thorough history and physical examination, followed by abdominal paracentesis to analyze ascitic fluid. The serum-ascites albumin gradient (SAAG) helps differentiate portal hypertension (SAAG ≥1.1 g/dL) from non-portal hypertension causes (SAAG <1.1 g/dL), as outlined in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1. Additional tests include cell count, culture, cytology, and albumin levels. Management of cirrhotic ascites involves sodium restriction (2000 mg/day), fluid restriction in hyponatremia, and diuretic therapy, with the goal of achieving a rate of weight loss of no greater than 0.5 kg/day in patients without peripheral edema and 1 kg/day in those with peripheral edema, as recommended by the European Association for the Study of the Liver (EASL) guidelines 1. For refractory ascites, therapeutic paracentesis with albumin replacement (6-8 g per liter of fluid removed for large-volume paracentesis >5L) or transjugular intrahepatic portosystemic shunt (TIPS) may be necessary, as discussed in the EASL guidelines 1. Spontaneous bacterial peritonitis requires immediate antibiotic treatment, typically with cefotaxime 2g IV every 8 hours for 5-7 days. Patients with ascites should be monitored for complications including spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic hydrothorax, and liver transplantation should be considered for appropriate candidates with end-stage liver disease, as recommended by the American Association for the Study of Liver Diseases guidelines 1.

Some key points to consider in the management of ascites include:

• The use of diuretics, such as spironolactone and furosemide, to promote sodium excretion and reduce ascites fluid accumulation, as recommended by the EASL guidelines 1.
• The importance of monitoring serum electrolyte concentrations and adjusting diuretic doses accordingly, as outlined in the 2021 practice guidance by the American Association for the Study of Liver Diseases 1.
• The role of therapeutic paracentesis and albumin replacement in the management of refractory ascites, as discussed in the EASL guidelines 1.
• The need for careful consideration of the risks and benefits of hernia repair in patients with cirrhosis and ascites, as recommended by the American Association for the Study of Liver Diseases guidelines 1.

Overall, the management of ascites requires a comprehensive and individualized approach, taking into account the underlying cause, severity, and complications of the condition, as well as the patient's overall health status and quality of life, as recommended by the most recent guidelines 1.

From the FDA Drug Label

By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions. The approach to ascitis involves the use of spironolactone as an aldosterone antagonist to provide effective therapy for edema and ascites in conditions such as hepatic cirrhosis 2.

• The treatment should be initiated with caution, monitoring for potential side effects such as hyperkalemia, hypotension, and worsening renal function 2.
• In patients with hepatic cirrhosis and ascites, furosemide therapy may also be considered, but it is best initiated in the hospital with strict observation during the period of diuresis 3.
• The use of potassium supplementation and aldosterone antagonists may be helpful in preventing hypokalemia and metabolic alkalosis 3.

From the Research

Approach to Ascitis

• Ascitis is the most common complication of cirrhosis, occurring in more than half of all patients with cirrhosis 4.
• The development of ascitis indicates progression of the underlying cirrhosis and is associated with a 50% 2-year survival rate 4.
• Successful treatment is dependent on accurate diagnosis of the cause of ascitis, with sodium and water retention being the basic abnormality leading to ascitis formation 5.

Medical Therapy

• Restriction of sodium intake to 2 gram per day is usually advised 5, 6.
• Diuretic therapy is the mainstay of treatment, with spironolactone being the first-choice agent, often combined with furosemide 5, 4, 7, 8.
• The recommended initial dose is spironolactone 100-200 mg/d and furosemide 20-40 mg/d, with usual maximum doses being 400 mg/d of spironolactone and 160 mg/d of furosemide 5.

Large-Volume Paracentesis

• Large-volume paracentesis (LVP) is a effective treatment for cirrhotic patients with tense ascitis, especially when associated with intravenous albumin infusion 4, 7.
• LVP provides rapid resolution of symptoms with minimal complications and is well tolerated by most patients 4.
• Post-paracentesis circulatory dysfunction (PPCD) may occur after LVP and is characterized by hyponatremia, azotemia, and an increase in plasma renin activity, which can be prevented by administration of albumin intravenously 4.

Refractory Ascitis

• Refractory ascitis is defined as fluid overload that is unresponsive to sodium restricted diet and high dose diuretic treatment, or when there is an inability to reach maximal dose of diuretics because of adverse effects 5, 4.
• Treatment options for patients with refractory ascitis include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), peritoneovenous shunt, and liver transplantation 5, 4.
• Liver transplantation is the only modality that is associated with improved survival 5, 4.