What is the management for a patient with liver failure, gross ascites, and hypoalbuminemia?

Management of Liver Failure with Gross Ascites and Hypoalbuminemia

For a patient with liver failure, gross ascites, and low albumin, perform large-volume paracentesis as first-line therapy with mandatory albumin infusion (8 g per liter of ascites removed for volumes >5L), followed by sodium restriction and diuretic therapy, while immediately evaluating for liver transplantation. 1

Immediate Assessment and Initial Management

Diagnostic Paracentesis

• Perform diagnostic paracentesis on admission to rule out spontaneous bacterial peritonitis (SBP), even without obvious signs of infection 1
• Send ascitic fluid for cell count with differential (inoculate into blood culture bottles at bedside) and calculate serum-ascites albumin gradient 1
• If neutrophil count ≥250 cells/mm³, initiate empiric antibiotics immediately (third-generation cephalosporin such as cefotaxime) 1

Volume Status and Renal Function

• Check baseline serum creatinine, electrolytes (particularly sodium), and albumin level 2
• If creatinine is elevated (>150 μmol/L or rising), immediately stop all diuretics and initiate volume expansion with intravenous albumin 2
• Assess for acute kidney injury or hepatorenal syndrome, as this significantly worsens prognosis and requires urgent transplant evaluation 2

Large-Volume Paracentesis (Primary Treatment)

Procedure

• Therapeutic paracentesis is the first-line treatment for gross ascites 1
• Use ultrasound guidance when available to reduce adverse events 1
• Drain all ascitic fluid to dryness in a single session (typically over 1-4 hours) under strict sterile conditions 1
• Do NOT routinely check prothrombin time/platelet count or transfuse blood products before paracentesis 1

Albumin Replacement (Critical)

• For paracentesis >5 liters: Administer 20% or 25% albumin solution at 8 g per liter of ascites removed after paracentesis is completed 1
• This is a strong recommendation with high-quality evidence that reduces post-paracentesis circulatory dysfunction by 61%, hyponatremia by 42%, and mortality by 36% 1
• For paracentesis <5 liters: Consider albumin at same dose (8 g/L) if patient has acute-on-chronic liver failure or high risk of acute kidney injury 1
• Albumin is superior to synthetic plasma expanders (dextran, gelofusine) in preventing renal impairment and complications 1

Sodium and Fluid Management

Dietary Sodium Restriction

• Restrict dietary sodium to 90 mmol/day (5.2 g salt/day) with a no-added-salt diet 1
• This is fundamental to ascites management and should be maintained throughout treatment 1

Fluid Restriction

• Do NOT routinely restrict fluids 1
• Reserve fluid restriction (1-1.5 L/day) only for patients with severe hyponatremia (serum sodium <125 mmol/L) AND clinical hypervolemia 1

Hyponatremia Management Algorithm

• Serum sodium 126-135 mmol/L with normal creatinine: Continue diuretics, monitor electrolytes closely, no fluid restriction 1
• Serum sodium 121-125 mmol/L with normal creatinine: Stop or reduce diuretics cautiously 1
• Serum sodium 121-125 mmol/L with elevated creatinine (>150 μmol/L): Stop diuretics immediately and give volume expansion with albumin or colloid 1, 2
• **Serum sodium <120 mmol/L**: Stop diuretics, give volume expansion with albumin, but avoid increasing sodium by >12 mmol/L per 24 hours to prevent central pontine myelinolysis 1, 2

Diuretic Therapy (After Paracentesis)

Initiation and Dosing

• Reinitiate diuretics 1-2 days after paracentesis to prevent ascites recurrence (occurs in 93% without diuretics vs 18% with spironolactone) 1
• Start with spironolactone alone at 100 mg/day, increasing to maximum 400 mg/day as first-line 1
• If spironolactone alone fails, add furosemide up to 160 mg/day with careful biochemical and clinical monitoring 1

Monitoring and Adjustment

• Monitor serum electrolytes, creatinine, and blood pressure closely 1
• If patient develops hypotension or progressive renal dysfunction, reduce or discontinue diuretics 1

Special Considerations

Spontaneous Bacterial Peritonitis (If Present)

• If SBP diagnosed with elevated or rising creatinine: Give albumin 1.5 g/kg within 6 hours of diagnosis, followed by 1 g/kg on day 3, in addition to antibiotics 1
• This reduces renal impairment (10% vs 33%) and mortality (22% vs 41%) compared to antibiotics alone 1

Refractory Ascites

• If ascites persists despite maximum diuretic therapy and repeated paracentesis, consider transjugular intrahepatic portosystemic shunt (TIPSS) 1
• Exercise caution with TIPSS if: age >70 years, bilirubin >50 μmol/L, platelets <75×10⁹/L, MELD ≥18, current hepatic encephalopathy, active infection, or hepatorenal syndrome 1

Non-Selective Beta-Blockers

• Refractory ascites is NOT a contraindication to beta-blockers 1
• However, monitor closely and consider dose reduction or discontinuation if hypotension or acute/progressive renal dysfunction develops 1

Liver Transplantation Evaluation

Refer immediately for liver transplantation evaluation 1, 2

• Development of ascites is a critical landmark indicating hepatic decompensation and significantly reduced survival 1
• Presence of acute kidney injury, SBP, or refractory ascites further prioritizes transplant need 1, 2

Common Pitfalls to Avoid

• Never withhold albumin after large-volume paracentesis (>5L) - this leads to post-paracentesis circulatory dysfunction with renal impairment and increased mortality 1
• Do not routinely restrict fluids unless severe hyponatremia with hypervolemia is present 1
• Do not continue diuretics if creatinine is rising - this worsens renal perfusion in established acute kidney injury 2
• Do not delay diagnostic paracentesis - SBP can present without obvious peritoneal signs and requires immediate treatment 1
• Avoid correcting sodium too rapidly (>12 mmol/L per 24 hours) to prevent central pontine myelinolysis 1, 2