Diuretic Management in Patients with Elevated Liver Enzymes

Rationale for Holding Diuretics

• Patients with liver dysfunction often have altered hemodynamics with reduced effective arterial blood volume, which can be further compromised by diuretic therapy 1, 3
• Elevated liver enzymes may indicate progression of liver disease, which is associated with increased risk of hepatorenal syndrome when diuretics are continued 2

Risk of Complications

• Diuretics can precipitate acute kidney injury in patients with compromised liver function due to further reduction in effective circulating volume 2, 3
• Patients with liver dysfunction are at higher risk for developing severe hyponatremia, hypokalemia, or hyperkalemia with diuretic use 4, 5
• Diuretic therapy can precipitate or worsen hepatic encephalopathy in patients with liver dysfunction 1, 4

Clinical Guidelines for Diuretic Management

• The American Association for the Study of Liver Diseases recommends discontinuing diuretics in patients with severe hyponatremia (serum sodium <125 mmol/L) 2, 5
• Diuretics should be held in patients with acute kidney injury or rising serum creatinine 2
• The European Association for the Study of the Liver suggests discontinuing diuretics in patients with worsening hepatic encephalopathy 1, 2

Management Approach for Patients with Liver Disease and Fluid Overload

• The American Association for the Study of Liver Diseases recommends beginning with spironolactone monotherapy (starting at 100 mg/day) for first presentation of moderate ascites 6
• For recurrent or severe ascites, consider combination therapy with spironolactone (100-400 mg) and furosemide (40-160 mg) 6
• Limit weight loss to 0.5 kg/day in patients without edema and 1 kg/day in those with edema 2

Alternative Management Strategies When Diuretics Are Contraindicated

• Large volume paracentesis (LVP) with albumin replacement (8g albumin/L of ascites removed) for patients with large ascites 6
• Consider transjugular intrahepatic portosystemic shunt (TIPSS) for refractory ascites 6
• Moderate salt restriction (5-6.5g daily) and nutritional counseling 6
• In select cases of refractory ascites, midodrine may be considered 6