COMMENTARY

Management of Ascites

Rowen K. Zetterman, MD

Disclosures

April 05, 2011

In This Article

Treatment of Ascites

Diet and Diuretics

Most patients with ascites will respond to a sequential program of reduced dietary sodium intake with addition of diuretics in a stepwise fashion.[17] Spironolactone is typically administered first, followed by furosemide or hydrochlorothiazide if diuresis is inadequate. Patients with ascites should avoid nonsteroidal anti-inflammatory drugs because they interfere with diuretic effectiveness as a result of prostaglandin inhibition and may add to renal insufficiency through a reduction of renal blood flow and reduced glomerular filtration rate.[18]

Sequential approach. In patients with first-time ascites, a low-sodium diet of 40 to 80 mEq (1000-2000 mg) per day alone may lead to resolution of ascites. If not, diuretics should be added. Spironolactone, a distal tubular diuretic and aldosterone antagonist, has a long half-life and its peak effect may not be reached until 3 to 7 days after administration. The author suggests starting at 100 mg/day and increasing to 200 mg daily if weight loss of 0.5 kg/day is not achieved by the third day. Spironolactone can add to the metabolic acidosis associated with cirrhosis and may cause hyperkalemia, so it might be necessary to limit intake of dietary potassium. Other distal tubular diuretics that can be used include amiloride and triamterene. If needed, furosemide is a loop diuretic that is readily absorbed and has a short half-life. It is effective in most patients with ascites, although excessive sodium reabsorption in the proximal tubule can prevent generation of an adequate sodium concentration by the loop of Henle and reduce the effectiveness of furosemide. After an initial low-sodium diet and administration of spironolactone, furosemide 40 mg/day can be added and increased in a stepwise fashion up to 160 mg daily if weight loss of 0.5 kg/day does not ensue. Serum creatinine, blood urea nitrogen, sodium, and potassium levels should be measured periodically.

Complications of diuretic therapy. Renal dysfunction may develop as a consequence of diuretic therapy.[19] Renal function will improve in most patients with diuretic dose reduction. Hyponatremia occurs as a consequence of impaired free water clearance in cirrhosis. Oral fluid intake may need to be reduced to improve serum sodium levels. Rapid correction of serum sodium levels with intravenous sodium should generally be avoided. Other complications of diuretics include a worsening of hepatic encephalopathy from diuretic-induced hypokalemia and alkalosis or from increased ammonium production in the kidney. Spironolactone therapy can result in breast tenderness and gynecomastia.

Paracentesis

If patients do not respond to diuretics, large volume paracentesis of 4 to 6 liters of ascites should be performed as frequently as needed to control fluid formation.[20] Azotemia may develop from large volume paracentesis, and the administration of 25% albumin for volume expansion will reduce the intravascular effects of paracentesis.[21] If less than 5 liters of ascitic fluid is removed and renal function is normal, additional albumin is not needed. However, if renal insufficiency is present, albumin administration should be considered. When 5 or more liters of ascites are removed, 6 to 8 grams of 25% albumin should be administered for every liter of ascites removed. Administration of norepinephrine following large volume paracentesis may be as effective as albumin in preventing circulatory dysfunction.[22]

A transjugular intrahepatic portosystemic shunt (TIPS) can control ascites in patients with end-stage liver disease.[23] A TIPS will reduce portal pressure and decrease lymph formation within the liver, while increasing venous return to the heart and improving cardiac output. Following TIPS placement in patients with refractory ascites or hepatic hydrothorax, improvement of ascites occurs in 22% to 74% of patients.

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