In a patient with alcoholic cirrhosis and tense ascites refractory to maximal spironolactone (100–400 mg daily) and furosemide (40–160 mg daily) on a low‑sodium diet (≤2 g/day), is weekly therapeutic paracentesis appropriate and should albumin be administered with each large‑volume paracentesis?

Weekly Paracentesis for Alcohol-Related Ascites

In patients with alcoholic cirrhosis and refractory ascites despite maximal diuretic therapy (spironolactone 400 mg + furosemide 160 mg daily) and sodium restriction, serial therapeutic paracentesis every 2–3 weeks with albumin replacement (8 g per liter removed) is appropriate and necessary, but this should not replace continued diuretic therapy and sodium restriction. 1, 2

Definition of Refractory Ascites

Your patient meets criteria for refractory ascites, defined as fluid overload that either:

• Fails to respond to sodium restriction (≤2 g/day) plus maximum diuretic doses (spironolactone 400 mg + furosemide 160 mg daily), OR
• Recurs rapidly after therapeutic paracentesis 1, 3

Approximately 10% of cirrhotic patients with ascites eventually develop refractory disease. 4

Why Serial Paracentesis Is Appropriate

Serial therapeutic paracentesis is the initial treatment of choice for refractory ascites because:

• It provides immediate symptom relief within minutes versus days-to-weeks with diuretics alone 2
• Two randomized controlled trials (158 patients total) demonstrated that large-volume paracentesis is safer and more effective than high-dose diuretics for tense ascites, with significantly lower rates of hepatic encephalopathy, renal impairment, electrolyte disturbances, and hemodynamic instability 2
• It shortens hospital length of stay and reduces complications compared to diuretics alone 5

Albumin Administration Is Mandatory

You must administer intravenous albumin with each large-volume paracentesis:

• Give 8 g of albumin per liter of ascitic fluid removed 1, 2, 5
• This prevents post-paracentesis circulatory dysfunction and preserves hemodynamic stability 2
• For removal of ≤5 L, paracentesis can be performed without colloid, but albumin is still recommended when larger volumes are extracted 1, 2
• The FDA label confirms albumin's indication for "removal of ascitic fluid from a patient with cirrhosis" to prevent hypovolemic shock 6

Critical: Continue Diuretics and Sodium Restriction

A common pitfall is stopping diuretics after initiating serial paracentesis—this is incorrect:

• Paracentesis alone does nothing to correct the underlying sodium retention pathophysiology 1, 2
• Continue maximum tolerated diuretic doses (spironolactone 400 mg + furosemide 160 mg daily) to minimize fluid reaccumulation 1, 5
• Maintain strict sodium restriction (88 mmol/day or 2 g/day) 1, 5
• Serial paracentesis without concurrent diuretic therapy fails to address underlying pathophysiology and is discouraged 2

Monitoring Between Paracenteses

Between procedures, monitor closely for:

• Diuretic complications: hepatic encephalopathy, serum creatinine >2.0 mg/dL, serum sodium <120 mmol/L, hyperkalemia >6.0 mmol/L 1
• Target weight loss of 0.5 kg/day without peripheral edema, or 1 kg/day with edema 5
• Avoid NSAIDs completely—they impair sodium excretion, cause azotemia, and can convert diuretic-responsive patients to refractory status 1, 2

When to Consider TIPS

Transjugular intrahepatic portosystemic shunt (TIPS) should be considered if:

• The patient repeatedly fails large-volume paracentesis (requiring frequent procedures) 1, 7
• The patient has relatively preserved liver function 7
• TIPS is contraindicated if: current hepatic encephalopathy, age >70 years, bilirubin >50 μmol/L, or MELD score ≥18 2

Urgent Liver Transplant Evaluation

This patient requires immediate transplant evaluation:

• Development of ascites in cirrhosis confers 50% mortality within 2 years 2
• Once ascites becomes refractory to medical therapy, mortality rises to 50% within 6 months 2
• Liver transplantation is the only definitive therapy that improves survival in refractory ascites 3, 8, 7
• Renal dysfunction commonly accompanies refractory ascites and largely improves after transplant without affecting post-transplant survival 4

Practical Algorithm for This Patient

1. Perform therapeutic paracentesis every 2–3 weeks as needed for symptom control 9, 8
2. Administer albumin 8 g per liter removed with each procedure 1, 2, 5
3. Continue maximum diuretics (spironolactone 400 mg + furosemide 160 mg daily) unless contraindicated 1, 5
4. Maintain sodium restriction ≤2 g/day 1, 5
5. Refer urgently for liver transplant evaluation 2, 7, 4
6. Consider TIPS if requiring paracentesis more frequently than every 2–3 weeks and no contraindications exist 2, 7
7. Ensure alcohol abstinence—patients with alcohol-related liver injury must abstain completely 1