Management of Ascites in Liver Cirrhosis

Initial Assessment and Treatment Approach

The American Association for the Study of Liver Diseases recommends first-line treatment for patients with cirrhosis and ascites to consist of dietary sodium restriction to 88 mmol/day (2000 mg/day) and oral diuretics (spironolactone and furosemide) 1, 2, 3
Dietary sodium restriction to 88 mmol/day (2000 mg/day or approximately 5g salt/day) is equivalent to a "no added salt" diet, as recommended by the European Association for the Study of the Liver 4, 2
Oral diuretics are the mainstay of pharmacological treatment, with spironolactone 100 mg once daily as the initial dose, according to the American Association for the Study of Liver Diseases 1, 2, 5
Furosemide 40 mg once daily can be added if needed, as recommended by the American Association for the Study of Liver Diseases 2
Doses can be increased simultaneously every 3-5 days (maintaining the 100 mg:40 mg ratio) if weight loss and natriuresis are inadequate, as suggested by the European Association for the Study of the Liver 6
Maximum doses are typically 400 mg/day of spironolactone and 160 mg/day of furosemide, according to the American Association for the Study of Liver Diseases 7, 6

Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L, as recommended by the American Association for the Study of Liver Diseases 1, 2, 3
Patients with ascites who have an alcohol component to their liver injury should abstain from alcohol consumption, according to the American Association for the Study of Liver Diseases 1, 2, 3
Abstinence can result in dramatic improvement in the reversible component of alcoholic liver disease, as suggested by the American Association for the Study of Liver Diseases 1

Recommended nutritional intake is 2-3 g/kg/day carbohydrate, 1.2-1.5 g/kg/day protein, and 35-40 kcal/kg/day, as recommended by the European Association for the Study of the Liver 4
Smaller, frequent meals may be beneficial if three meals per day do not provide adequate nutrition, according to the European Association for the Study of the Liver 4
A late-evening snack of 200 kcal can improve nutritional status, as suggested by the European Association for the Study of the Liver 4

Monitor serum electrolytes, creatinine, and weight regularly, as recommended by the American Association for the Study of Liver Diseases 6
Measure 24-hour urinary sodium excretion if weight loss is less than desired, according to the American Association for the Study of Liver Diseases 2
Frequency of follow-up is determined by response to treatment and stability of the patient, as suggested by the American Association for the Study of Liver Diseases 7

Refractory ascites is defined as fluid overload that is unresponsive to sodium-restricted diet and high-dose diuretic treatment (400 mg/day spironolactone and 160 mg/day furosemide), or recurs rapidly after therapeutic paracentesis, according to the American Association for the Study of Liver Diseases 9, 7, 8
Serial therapeutic paracenteses (every 2-3 weeks as needed) can be used to manage refractory ascites, as recommended by the American Association for the Study of Liver Diseases 7, 8
Transjugular intrahepatic portosystemic stent-shunt (TIPS) can be considered in selected patients, according to the American Association for the Study of Liver Diseases 8
Liver transplantation should be considered for patients with refractory ascites, as recommended by the European Association for the Study of the Liver 10, 8

Avoid nonsteroidal anti-inflammatory drugs as they can reduce urinary sodium excretion and induce azotemia, as recommended by the American Association for the Study of Liver Diseases 7, 8
For large-volume paracentesis (>5L), albumin infusion (8g/L of ascites removed) is recommended to prevent circulatory dysfunction, according to the European Association for the Study of the Liver 5
Liver transplantation offers a definitive cure for cirrhosis and its complications, as suggested by the European Association for the Study of the Liver 10

Development of ascites is associated with poor prognosis - 20% of those presenting with ascites die in the first year of diagnosis, according to the European Association for the Study of the Liver 10