From the Guidelines
Diuretics are essential in managing end-stage liver disease (ESLD) complications, particularly ascites and edema, with the first-line treatment being a combination of spironolactone and furosemide, typically starting with spironolactone 100mg and furosemide 40mg daily, as recommended by the most recent guidelines 1. The combination of spironolactone and furosemide works synergistically, with spironolactone blocking aldosterone receptors in the distal tubule and furosemide inhibiting sodium reabsorption in the loop of Henle.
- The dosage can be gradually increased to spironolactone 400mg and furosemide 160mg daily if needed, while maintaining a 100:40 ratio to prevent electrolyte imbalances, as suggested by 1 and 1.
- Patients should be monitored closely for complications including hyponatremia, hypokalemia, metabolic alkalosis, renal impairment, and hepatic encephalopathy.
- Dietary sodium restriction (5-6.5 gms/day) should accompany diuretic therapy, as recommended by 1.
- For patients with refractory ascites not responding to maximum diuretic doses, large-volume paracentesis or transjugular intrahepatic portosystemic shunt (TIPS) may be necessary, as stated in 1.
- Diuretic therapy should be temporarily reduced or discontinued if complications like hyponatremia (sodium <125 mEq/L), acute kidney injury, or hepatic encephalopathy develop, as advised by 1 and 1.
- Weight loss should be limited to 0.5kg/day in patients without edema and 1kg/day in those with edema to prevent rapid fluid shifts, as recommended by 1 and 1.
From the FDA Drug Label
In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. Supplemental potassium chloride and, if required, an aldosterone antagonist are helpful in preventing hypokalemia and metabolic alkalosis Sudden alterations of fluid and electrolyte balance in patients with cirrhosis may precipitate hepatic coma; therefore, strict observation is necessary during the period of diuresis.
For patients with end-stage liver disease, diuretics such as furosemide and spironolactone can be used, but with caution.
- Furosemide therapy is best initiated in the hospital for patients with hepatic cirrhosis and ascites.
- Spironolactone can cause hyperkalemia, and its use requires monitoring of serum potassium levels.
- The use of diuretics in patients with end-stage liver disease requires strict observation to prevent complications such as hepatic coma and electrolyte imbalance 2.
- It is also important to monitor volume status and renal function periodically when using diuretics in these patients 3.
From the Research
Diuretics for End-Stage Liver Disease
- Diuretics are a mainstay in the treatment of ascites in patients with cirrhosis, with the goal of enhancing sodium excretion and restricting sodium intake 4.
- The recommended initial doses of diuretics are spironolactone 100-200 mg/d and furosemide 20-40 mg/d, with maximum doses of 400 mg/d of spironolactone and 160 mg/d of furosemide 4.
- Studies have shown that spironolactone is more effective than furosemide in eliminating ascites in cirrhotic patients, particularly in those with avid sodium retention and high renin and aldosterone levels 5, 6.
Treatment Options
- For patients with mild ascites, diuretic therapy is the initial treatment of choice 5, 7.
- For patients with tense ascites, large-volume paracentesis associated with intravenous albumin infusion is the treatment of choice, followed by diuretic therapy to prevent reaccumulation of ascites 7.
- Peritoneovenous shunt is an effective treatment for ascites in cirrhosis, particularly in patients who do not respond to diuretics and develop repeated episodes of ascites despite adequate treatment 7.
Response to Diuretic Therapy
- About 90% of patients respond well to medical therapy for ascites, with a response rate of 98% in patients treated with spironolactone and furosemide, and 94% in patients treated with spironolactone alone 4, 8.
- The diuretic response is related to the activity of the renin-aldosterone system, with patients having higher renin and aldosterone levels requiring higher doses of spironolactone to achieve a diuretic response 6.