Management of Compensated Cirrhosis

Introduction to Compensated Cirrhosis

Patients with compensated cirrhosis do not routinely require spironolactone or furosemide unless they have developed ascites, as recommended by the American Association for the Study of Liver Diseases 1, 2

Diuretics are primarily indicated when ascites develops, which is a sign of decompensation, according to the European Association for the Study of the Liver 3, 5
The American Association for the Study of Liver Diseases recommends sodium restriction (88 mmol/day or 2000 mg/day) as first-line treatment for ascites 3, 6
Spironolactone is the primary diuretic of choice, starting at 50-100 mg/day, as suggested by the American Association for the Study of Liver Diseases 1, 4
Furosemide can be added as a combination therapy or sequentially, with a starting dose of 20-40 mg/day, according to the American Association for the Study of Liver Diseases 1, 2

The ratio of 100 mg spironolactone to 40 mg furosemide helps maintain normal potassium levels, as recommended by the European Association for the Study of the Liver 2, 7
Weight loss (target 0.5 kg/day in the absence of peripheral edema) should be monitored, along with serum electrolytes, particularly potassium and sodium, and renal function (serum creatinine), as suggested by the American Association for the Study of Liver Diseases 1, 4, 7

Initial large-volume paracentesis followed by diuretic therapy is recommended for tense ascites, with 6-8 g of albumin infused per liter of ascites drained, according to the American Association for the Study of Liver Diseases 1, 3, 6
Diuretics should be discontinued in cases of severe hyponatremia (serum sodium <120-125 mmol/L), acute kidney injury, hepatic encephalopathy, or severe muscle cramps, as recommended by the American Association for the Study of Liver Diseases 1, 2, 6
Refractory ascites is defined as ascites unresponsive to sodium restriction and maximum doses of diuretics (spironolactone 400 mg/day and furosemide 160 mg/day), and management options include serial therapeutic paracenteses, TIPS, or liver transplantation, according to the European Association for the Study of the Liver 1, 5, 6