What is the appropriate management for a patient with chronic liver disease who has developed ascites, including sodium restriction, diuretic therapy, large‑volume paracentesis with albumin, SBP screening and prophylaxis, and consideration of TIPS or transplantation?

Management of Chronic Liver Disease with Ascites

All patients with cirrhotic ascites should be immediately evaluated for liver transplantation, as development of ascites signals hepatic decompensation with 50% mortality within 2 years, and transplantation is the only definitive treatment that improves survival. 1

Initial Diagnostic Evaluation

Perform diagnostic paracentesis on every cirrhotic patient with new-onset ascites or hospital admission with known ascites to confirm portal hypertension, exclude spontaneous bacterial peritonitis (SBP), and guide therapy. 1, 2

Essential Ascitic Fluid Analysis

• Calculate serum-ascites albumin gradient (SAAG): A SAAG ≥1.1 g/dL confirms portal hypertension-related ascites with 97% accuracy. 2, 3
• Measure ascitic fluid neutrophil count: >250 cells/mm³ defines SBP and mandates immediate empiric antibiotics. 1, 2
• Inoculate 10 mL of ascitic fluid into blood culture bottles at the bedside to maximize bacterial recovery. 1, 2
• Measure total ascitic protein: Concentrations <15 g/L identify patients at high risk for SBP who may benefit from prophylaxis. 2
• Order amylase, cytology, or adenosine deaminase only when clinical suspicion exists for pancreatic disease, malignancy, or tuberculosis. 2

Baseline Laboratory and Imaging Work-up

• Obtain liver function tests, serum creatinine, BUN, electrolytes (especially sodium), coagulation profile, and complete blood count. 2
• Perform abdominal ultrasound to assess liver morphology, splenomegaly, portal vein patency, and exclude alternative causes. 2
• Do not delay paracentesis for coagulopathy or thrombocytopenia; serious bleeding occurs in <0.1% of procedures, and routine correction of INR or platelet count is unnecessary. 2, 4

First-Line Medical Management

Dietary Sodium Restriction

• Restrict dietary sodium to 90 mmol/day (5.2 g salt/day), essentially a "no added salt" diet. 1, 2
• Bed rest provides no benefit and is not recommended. 1
• Water restriction is unnecessary unless severe hyponatremia (<120-125 mmol/L) develops. 1, 5

Diuretic Therapy for Uncomplicated Ascites

Start spironolactone monotherapy at 100 mg daily as first-line treatment, titrating up to 400 mg daily if response is inadequate. 1, 2, 5

• If spironolactone alone fails to resolve ascites, add furosemide up to 160 mg daily with careful biochemical and clinical monitoring. 1, 2
• For hospitalized patients with recurrent or severe ascites, initiate combination therapy with spironolactone 100 mg plus furosemide 40 mg daily. 2, 5
• Target weight loss of 0.5 kg/day (or 1 kg/day if peripheral edema is present). 2
• Monitor serum electrolytes, creatinine, and daily weight within 2-3 days of any dose change, then weekly during the first month. 2, 5

Management of Hyponatremia During Diuretic Therapy

Serum Sodium (mmol/L)	Renal Function	Action
126-135	Normal creatinine	Continue diuretics; monitor electrolytes closely; no water restriction [1,2]
121-125	Normal creatinine	Stop or reduce diuretics cautiously [1,2]
121-125	Elevated creatinine (>150 μmol/L or rising)	Stop diuretics immediately; provide volume expansion [1,2]
<120	Any	Stop diuretics; volume expansion with colloid or saline; avoid sodium rise >12 mmol/L per 24 hours to prevent osmotic demyelination [1,2]

Large-Volume Paracentesis

Therapeutic paracentesis is the first-line treatment for patients with large or tense ascites, providing rapid symptom relief superior to diuretics alone. 1, 2, 5, 4

Procedure Technique

• Perform complete drainage in a single session regardless of volume, completing within 1-4 hours. 1, 2, 4
• Insert needle in the left lower quadrant (preferred) or right lower quadrant, at least 8 cm from midline and 5 cm above symphysis pubis, using "Z-track" technique. 4
• Use ultrasound guidance when available to reduce adverse events. 2, 4
• Do not leave drainage catheter in place overnight. 4

Albumin Replacement Protocol

For paracentesis <5 L: Administer synthetic plasma expander (150-200 mL gelofusine or Haemaccel); albumin is not required unless the patient has acute-on-chronic liver failure or high risk of post-paracentesis acute kidney injury. 1, 2, 4

For paracentesis ≥5 L: Mandatory albumin replacement at 8 g per liter of ascites removed (approximately 100 mL of 20% albumin per 3 L removed), infused after paracentesis completion over 1-2 hours. 1, 2, 4, 6

• Albumin prevents post-paracentesis circulatory dysfunction (PICD), reducing renal impairment from 21% to 0%, and decreasing hyponatremia and mortality. 4, 6
• Albumin is superior to synthetic plasma expanders (dextran-70, polygeline) for volumes >5 L. 4, 6

Spontaneous Bacterial Peritonitis (SBP)

When to Suspect SBP

Perform immediate diagnostic paracentesis in all cirrhotic patients with ascites who develop: fever, abdominal pain, altered mental status, hepatic encephalopathy, worsening renal function, gastrointestinal bleeding, peripheral leukocytosis, or any systemic inflammatory signs without obvious precipitating factor. 1, 2

Empiric Treatment

Start empiric third-generation cephalosporin (e.g., cefotaxime) immediately when ascitic neutrophil count exceeds 250 cells/mm³, without awaiting culture results. 1, 2, 5, 6

• Administer albumin 1.5 g/kg within the first 6 hours, followed by 1.0 g/kg on day 3 in SBP patients with signs of developing renal impairment to prevent hepatorenal syndrome and reduce mortality. 1, 2, 5
• Consider repeat paracentesis at 48 hours if clinical response is inadequate or secondary bacterial peritonitis is suspected. 2

SBP Prophylaxis

After one episode of SBP, prescribe lifelong secondary prophylaxis with norfloxacin 400 mg daily (or ciprofloxacin 500 mg daily), which reduces SBP recurrence from 68% to 20%. 1, 2, 5

• Provide prophylactic antibiotics (e.g., cefotaxime or locally appropriate agent) to patients with gastrointestinal bleeding and ascites. 2, 5
• Primary prophylaxis may be considered in patients with ascitic fluid protein <15 g/L plus additional risk factors (Child-Pugh ≥9, serum bilirubin ≥3 mg/dL, renal impairment, or hyponatremia). 2
• Be aware that long-term quinolone prophylaxis increases gram-positive infections (79%), including methicillin-resistant Staphylococcus aureus. 1

Refractory Ascites

Refractory ascites is defined as ascites unresponsive to maximum tolerated doses of spironolactone 400 mg plus furosemide 160 mg daily with sodium restriction, or that recurs rapidly after therapeutic paracentesis. 2, 7

Management Options

Repeated large-volume paracentesis with albumin supplementation is the standard first-line approach for refractory ascites. 1, 2, 5, 4, 7

Transjugular intrahepatic portosystemic shunt (TIPS) should be considered for patients requiring frequent paracentesis (generally ≥3 per month) with appropriate risk-benefit assessment. 1, 2, 5

• TIPS offers superior long-term control of refractory ascites but may worsen hepatic encephalopathy and precipitate heart failure in patients with pre-existing cardiac disease. 1, 2, 7
• TIPS is contraindicated in patients with advanced liver failure (Model for End-Stage Liver Disease risk score >1.8), as it can hasten death. 1, 6
• TIPS does not improve survival without transplantation in most patients. 1, 6, 7

Prognostic Considerations and Transplant Referral

Development of ascites is associated with 50% mortality within 2 years and signals the need for immediate transplant evaluation. 1, 6, 3, 7

• Once ascites becomes refractory to medical therapy, 50% die within 6 months. 1, 6
• All patients with SBP should be considered for liver transplantation, as 1-year survival after SBP is only 30-50%, falling to 25-30% at 2 years. 1, 6
• Treatment of ascites improves quality of life and prevents complications but does not significantly improve survival without transplantation. 1, 2, 7
• Pre-transplant renal dysfunction leads to greater morbidity, delayed recovery, and prolonged intensive care unit stay following liver transplantation. 1

Common Pitfalls to Avoid

• Do not assume the cause of ascites without diagnostic paracentesis; approximately 25% of ascites cases in Western populations are due to non-cirrhotic etiologies (malignancy, heart failure, tuberculosis, pancreatic disease). 2
• Do not withhold paracentesis due to coagulopathy or thrombocytopenia; routine correction is unnecessary even with INR up to 8.7 or platelets as low as 19×10³/μL. 2, 4
• Avoid overly aggressive diuresis, which can precipitate hyponatremia, renal dysfunction, or hepatic encephalopathy and worsen outcomes. 2, 7
• Do not use albumin for uncomplicated ascites or paracentesis <5 L unless the patient has acute-on-chronic liver failure or high acute kidney injury risk. 2, 4
• Do not artificially slow paracentesis drainage rate out of concern for hemodynamic instability; this outdated practice delays symptom relief and is not supported by current evidence. 4