Management of Refractory Ascites in Patients with CKD and CLD
Serial large-volume paracentesis (LVP) with albumin replacement is the primary treatment for refractory ascites in patients with both chronic kidney disease and chronic liver disease, while TIPSS should be avoided due to the high risk of worsening renal function and mortality in this population. 1
Initial Assessment and Definition
Refractory ascites is defined as ascites that either fails to respond to maximum diuretic therapy (spironolactone 400 mg/day plus furosemide 160 mg/day) with sodium restriction (<5 g/day) for at least 1 week, or recurs within 4 weeks despite initial mobilization. 1 The presence of pre-existing CKD makes this patient particularly vulnerable to further renal deterioration, which is the primary concern driving management decisions. 1
Primary Treatment Strategy: Serial Large-Volume Paracentesis
Perform therapeutic paracentesis as the mainstay treatment, removing ascitic fluid as needed for symptomatic relief. 1
Albumin Replacement Protocol
For paracentesis >5 liters: Administer 8 g of albumin (20% or 25% solution) per liter of ascites removed immediately after completing the procedure. 1, 2
For paracentesis <5 liters in high-risk patients: Given the presence of CKD, this patient is at high risk for post-paracentesis acute kidney injury. Consider albumin replacement at 8 g/L even with smaller volume paracentesis. 1, 2
Never use normal saline for volume expansion in this setting, as it contains 154 mmol/L sodium and will worsen fluid overload and ascites. 2
Technical Considerations
Use ultrasound guidance during paracentesis to reduce adverse events. 1
Do not routinely check prothrombin time, platelet count, or transfuse blood products before paracentesis unless there is active bleeding. 1
Why TIPSS is Contraindicated in This Patient
TIPSS should NOT be performed in patients with pre-existing chronic kidney disease and refractory ascites. 1, 3
The 2021 Gut guidelines explicitly state that caution is required (meaning avoid or use extreme caution) when considering TIPSS in patients with hepatorenal syndrome or progressive renal failure. 1, 3 Your patient with CKD has baseline renal dysfunction that places them at unacceptably high risk for:
- Post-TIPSS hepatic encephalopathy (which occurs more frequently with renal impairment)
- Worsening renal function leading to dialysis dependence
- Increased mortality (1-year mortality with TIPSS is 33% overall, but substantially higher with renal dysfunction) 4, 3
Additional TIPSS contraindications to assess include age >70 years, bilirubin >50 μmol/L, platelets <75×10⁹/L, MELD ≥18, and current hepatic encephalopathy. 1, 3
Diuretic Management in the Setting of CKD
Stop or significantly reduce diuretics in patients with refractory ascites and CKD. 1
If serum creatinine is rising or >150 μmol/L, discontinue diuretics immediately. 1, 2
Monitor closely for diuretic-induced complications including hyponatremia (<125 mmol/L), hyperkalemia (>6 mmol/L), hypokalemia (<3 mmol/L), and acute kidney injury (creatinine increase >0.3 mg/dL within 48 hours). 1
If hypovolemic hyponatremia develops, stop diuretics and expand plasma volume with albumin (not saline). 1, 2
Sodium and Fluid Management
Restrict dietary sodium to ≤5 g/day (≤2 g sodium/day, 87-113 mmol/day). This means no added salt and avoidance of precooked meals. 1
Do NOT routinely restrict fluids unless the patient has severe hyponatremia (<125 mmol/L) with clinical hypervolemia. Fluid restriction can worsen effective hypovolemia and increase ADH secretion, paradoxically worsening hyponatremia. 1, 2
If severe hyponatremia with hypervolemia exists, restrict fluids to 1-1.5 L/day. 1
Nutritional Support
Provide protein supplementation at 1.2-1.5 g/kg/day to prevent sarcopenia and malnutrition, which are common in cirrhotic patients with refractory ascites. 1 Nutritional counseling on sodium content is essential. 1
Monitoring for Complications
Watch closely for:
Spontaneous bacterial peritonitis (SBP): If diagnosed with rising creatinine, give albumin 1.5 g/kg within 6 hours, then 1 g/kg on day 3 to prevent hepatorenal syndrome. 1, 2
Progressive renal dysfunction: Serial creatinine monitoring after each paracentesis is mandatory given baseline CKD. 1, 2
Hepatic encephalopathy: More common with renal dysfunction due to reduced ammonia clearance. 1
Palliative Care and Transplant Evaluation
Refer for palliative care consultation immediately if the patient is not a liver transplant candidate. 1 Refractory ascites carries very poor prognosis, with median survival of 6 months without transplantation. 5, 6
Initiate liver transplant evaluation urgently if the patient is a potential candidate, as refractory ascites with CKD represents advanced decompensation. 5, 6, 7 Transplantation should ideally occur before further renal deterioration to prevent compromising post-transplant outcomes. 6
Common Pitfalls to Avoid
Do not proceed with TIPSS in patients with baseline renal dysfunction—this will likely accelerate progression to dialysis-dependent renal failure. 1, 3
Do not use crystalloids (normal saline) for volume expansion—use albumin exclusively in cirrhotic patients with ascites and renal dysfunction. 2
Do not continue diuretics when creatinine is rising or already elevated—this worsens renal function without improving ascites control in refractory cases. 1
Do not restrict fluids routinely—only restrict when severe hyponatremia (<125 mmol/L) with clinical hypervolemia is present. 1, 2