Management of Cirrhotic Patients

Albumin Administration

• The American Association for the Study of Liver Diseases recommends administering albumin at 8 g per liter of ascites removed during large-volume paracentesis to prevent post-paracentesis circulatory dysfunction (PICD), with strong evidence (Level A1) for paracentesis >5 liters and moderate evidence (Level B1) for paracentesis <5 liters 1, 2
• For spontaneous bacterial peritonitis (SBP), the European Association for the Study of the Liver recommends an initial dose of 1.5 g/kg on day 1 followed by 1 g/kg on day 3, which significantly decreases the incidence of hepatorenal syndrome and reduces mortality 3
• Albumin administration significantly decreases the incidence of type 1 hepatorenal syndrome (from 30% to 10%) and reduces mortality from 29% to 10% compared with antibiotics alone in patients with SBP 4
• Administer albumin in conjunction with vasoconstrictors (e.g., terlipressin) for the treatment of hepatorenal syndrome, and consider albumin administration in patients with sodium levels indicative of severe hyponatremia (<120 mEq/L) 5, 4
• Recommended albumin doses are:

6, 1, 7

Paracentesis

• Paracentesis should be performed under strict sterile conditions, with ultrasound guidance considered to reduce adverse events, as recommended by the European Association for the Study of the Liver 2, 6
• Complete drainage to dryness in a single session is recommended to minimize complications, with careful monitoring of blood pressure to avoid hypotension, in patients undergoing paracentesis for abdominal ascites management, according to the European Association for the Study of the Liver 6, 2
• The puncture site should be at least 8 cm from the midline and 5 cm above the symphysis, and ultrasound guidance should be used when available to reduce the risk of adverse events, such as bleeding or organ injury, during paracentesis, as recommended by the European Association for the Study of the Liver 6
• After paracentesis, patients should lie on the opposite side for two hours if there is leakage of remaining ascitic fluid, and a purse-string suture around the drainage site may be considered to minimize the risk of ascitic fluid leakage, according to the European Association for the Study of the Liver 2, 6
• Drains should not be left in overnight to reduce infection risk, and paracentesis should be performed under strict sterile conditions, with careful monitoring for signs of infection and catheter-related sepsis, as recommended by guidelines from the American College of Chest Physicians and the European Association for the Study of the Liver 2, 6

Management of Ascites

• Dietary sodium restriction (2000 mg/day) is a mainstay of treatment for patients with cirrhosis and ascites 8
• Oral diuretics should be used in conjunction with albumin therapy, and fluid restriction is generally not necessary except in cases of severe hyponatremia 8
• Diuretics should be reintroduced within 1-2 days after paracentesis to manage the underlying condition and prevent further ascites accumulation, without increasing the risk of PICD, as recommended by guidelines from the American College of Chest Physicians and the European Association for the Study of the Liver 2, 6
• Avoidance of NSAIDs, ACE inhibitors, and angiotensin II antagonists is recommended in patients with ascites due to increased risk of renal impairment 3

Special Considerations

• Patients with acute-on-chronic liver failure (ACLF) or at high risk of post-paracentesis acute kidney injury may require albumin infusion even for paracentesis <5L, according to clinical guidelines 6, 9
• Repeated low-volume paracentesis should be avoided, as it offers no additional benefits and carries a higher risk of procedure-related complications, in patients with cirrhosis, as recommended by guidelines from the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 6
• The patient's overall condition and goals of care should be considered when determining the appropriate drainage volume and frequency, taking into account the potential benefits and risks of the procedure, and permanent or tunneled catheters should be reserved for specific situations, such as refractory ascites or malignant ascites, with careful consideration of the increased infection risk, according to guidelines from the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver 2, 6