Management of the Underlying Liver Disease
The most important initial step in treating patients with cirrhosis and ascites is to permit healing of the reversible component of the underlying liver disease. Abstinence from alcohol allows healing of the reversible component of alcoholic liver disease, so that ascites becomes more responsive to medical therapy or may even completely resolve.
Positive sodium balance causes ascites formation. To achieve negative sodium balance, sodium output must exceed intake. in the absence of diuretics, many patients with cirrhosis and ascites have almost no urinary sodium excretion. Reducing dietary sodium intake below total output leads to a reduction in fluid volume and weight in these patients. Instituting a low-sodium diet maximizes urinary excretion and fluid loss. Thus, sodium restriction to 2 g (ie, 88 mmol)/d is warranted in all patients with cirrhosis and ascites (Bernardi et al, 1993). Ascites may improve with discontinuation of the precipitating agent, such as saline infusions given perioperatively or as resuscitative measures during gastrointestinal (GI) bleeding.
Almost all patients with clinically detectable ascites will require diuretic therapy, especially those with moderate to tense ascites and positive sodium balance while on a sodium-restricted diet. Oral diuretics are best used syner-gistically with the combination of spironolactone and furosemide administered as a single morning dose in the ratio of 100:40 mg. This ratio usually maintains normokalemia. The dose of spironolactone and furosemide can be initiated at 100 mg and 40 mg, respectively, and titrated up until successful diuresis is achieved or the maximum doses of 400 mg and 160 mg, respectively, are reached. Single morning dosing enhances compliance (Runyon, 2002).
Spironolactone may cause gynecomastia and a prolonged holdover effect that could be problematic if hyperkalemia develops in the setting of renal insufficiency. These adverse effects can be avoided by substituting the short acting amiloride for spironolactone at a dose of 10 to 40 mg.
Contraindications to diuretic use include hepatic encephalopathy, serum sodium < 120 mmol/L, and renal insufficiency with serum creatinine > 2 mg/dL. Fluid restriction is not necessary for most patients with cirrhotic ascites and should be reserved for those with serum sodium < 120 mmol/L.
Tense ascites requires urgent management. Large-volume paracentesis (LVP) rapidly relieves tense ascites. A single 5-L paracentesis can be performed safely without colloid infusion. For patients with tense, diuretic-sensitive ascites, diuretic therapy should be initiated with LVP. colloid replacement should be considered optional after LVP of over 5 L. Albumin infusion (8 g/L of fluid removed) may help prevent asymptomatic laboratory abnormalities, but does not prolong survival after LVP (Antillon and Runyon, 1991).
Regular follow-up of these patients is essential for maximal therapeutic effect and minimal adverse effects. Body weight, orthostatic symptoms and signs, serum electrolytes, urea, and creatinine should be assessed regularly during follow-up. If the fluid overload is easily controlled, the frequency of clinical visit can be reduced.
The combination of a 2-g (ie, 88 mmol) diet sodium intake with proper doses of diuretics should achieve weight loss and a negative sodium balance in approximately 90% of patients. In contrast, patients who are gaining fluid weight during treatment may either be noncompliant with the diet or diuretic-resistant. Monitoring urinary sodium excretion allows assessment of dietary compliance. Total nonurinary sodium loss is less than 10 mmol/d in afebrile cirrhotic patients without diarrhea. Patients who are eating 88 mmol/d of sodium and excreting > 78 mmol/d of sodium in a 24-hour urine specimen (or having a random urine sodium/potassium ratio > 1) should lose weight. If the patient's weight increases despite urinary sodium loss in excess of prescribed sodium intake, then dietary indiscretion is the culprit. On the other hand, diuretics should be increased if suboptimal diuresis is accompanied by 24hour urinary sodium of less than 78 mmol or random urine sodium less than urine potassium.
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