Ascites Management in Cirrhosis

Management of Ascites in Patients with Cirrhosis: Recommendations and Considerations

• Drugs that aggravate effective arterial hypovolemia should be avoided in patients with portal hypertensive ascites, including NSAIDs, ACE inhibitors, ARBs, and nephrotoxic drugs.
• Alcohol withdrawal and etiology-based treatment should be considered important components of ascites treatment in cirrhotic patients, as they can improve ascites.
• Blocking the RAAS through ACE inhibitors or ARBs may have beneficial effects in reducing ascites formation but can lead to hypotension and renal dysfunction in patients with advanced cirrhosis and ascites.
• A moderate sodium restriction of 80-120 mmol/day or 5-6.5 g salt/day is recommended in patients with cirrhosis and ascites, achieved by avoiding pre-cooked meals and following a no-added salt policy.
• Aldosterone antagonists like spironolactone or potassium Canrenoate are first-line agents for ascites mobilization, while loop diuretics are commonly used in patients with long-standing ascites.
• A combination of an aldosterone antagonist and a loop diuretic is preferred in patients with persisting ascites or hospitalized patients requiring rapid diuresis, but there is conflicting evidence regarding sequential or combination therapy.
• Monitoring response to diuretic therapy is important, with 24-h urinary sodium measurements used to quantify natriuresis and guide therapy.
• Large volume paracentesis (LVP) is the treatment of choice for patients with tense ascites, with volume replacement using intravenous albumin to prevent PICD.
• Patients undergoing LVP should be started on diuretics to reduce the need for frequent paracentesis, and strict asepsis should be followed during the procedure.
• Paracentesis is usually safe, but bleeding events and ascitic fluid leakage can occur, with risk factors including renal failure and severe liver dysfunction.
• Routine prophylactic transfusion of fresh frozen plasma or platelets is not recommended before paracentesis, but the procedure should not be performed in the presence of DIC.
• Ultrasound guidance for paracentesis is beneficial in reducing complications and should be used when available.
• Careful monitoring and management of diuretic therapy and LVP can optimize ascites control and reduce complications in patients with cirrhosis and ascites.