Ascites

Overview

  • For people with cirrhosis and new onset or known ascites worrying signs or symptoms are abdominal pain, fever, worsening kidney function, and confusion
  • Perform a diagnostic paracentesis along with a history, physical and labs in any patient presenting to the emergency room, or those with symptoms or signs of infection, kidney dysfunction or encephalopathy
  • Patients with ascites may be candidates for a transjugular intrahepatic portosystemic shunt (TIPS) or for liver transplantation
  • Non-selective beta blockers (NSBB’s) and other blood pressure lowering medications may need to be adjusted in patients with ascites 
  • If a patient has decompensated cirrhosis consider contacting a liver specialist to discuss management advice and potential transplant candidacy

 

Blood work:

  • Basic labs (CBC, electrolytes, creatinine, albumin, PT, bilirubin, ALT)
  • Blood cultures (if suspicion for spontaneous bacterial peritonitis, polymorphonuclear cell count >250 cell/ml)

Ascites fluid analysis:

  • Fluid cell count and differential
  • Fluid culture and sensitivity (inoculate fluid directly into blood culture bottles)
  • Fluid prorenin
  • Fluid albumin
  • Ascites in cirrhosis (SAAG >11 g/dL, protein <25 g/L)

SAAG Differential Diagnosis

  • If certain diagnoses are suspected, additional testing may be needed: fluid cytology (malignancy), lipase (pancreatitis), triglycerides (chylous ascites), bilirubin (bile leak), TB culture (tuberculosis)

General Principles

  • Tips for advising sodium restriction ≤ 2 grams/day: be aware that this reduces diet palatability and intake. Consult a dietitian and provide resources such as Cirrhosis Care Alberta, Cirrhosis Care - Cirrhosis Nutrition, and The Nutrition in Cirrhosis Guide
  • Hold medications that predispose to fluid retention/kidney dysfunction, e.g. NSAIDS, amino glycosides, angiotensin-converting-enzyme inhibitors, angiotensin II antagonists or alpha1-adrenergic receptor blockers
  • Start diuretics and/or consider TIPS
  • There is no need for fluid restriction unless hyponatremia is severe or sudden
  • Promote patient self-management for ascites
  • Consider contacting a liver specialist to discuss management advice
  • Alcohol intake should be stopped 
 

General Principles

  • The mainstay of therapy for ascites is sodium restriction + diuretics. Spironolactone and furosemide are often given in combination in a ratio of 50 mg (spironolactone) to 20 mg (furosemide).  In cases of mild ascites, spironolactone monotherapy may be enough
  • Large volume paracentesis (≥ 5 L drained) is required for tense or refractory ascites. Give IV albumin (100 cc of 25% albumin (25 grams) for every 3 L ascites removed). With kidney dysfunction or hypotension, be more cautious with the amount of fluid that is drained off

Spironolactone Monotherapy

  • 50-100 mg orally in the morning

Amiloride (Substitute for Spironolactone)

  • Starting dose of 10 mg, where 10 mg = 100 mg of Spironolactone
  • Maximum does: 40 mg

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Dosing for Combination Diuretics

  • Starting dose: Spironolactone 50-100 mg in combination with Furosemide 20-40 mg orally in the morning
  • If the electrolytes and creatinine remain normal, doses can be increased in increments of 50-100 mg Spironolactone to 20-40 mg Furosemide after 4-7 days

If hyperkalemia develops, reduce Spironolactone

  • The Spironolactone to Furosemide ratio of 50 mg:20 mgoften works to balance electrolytes, but must be individualized

Large-volume (≥ 5L) paracentesis AND start combination diuretics if no contraindications

  • Give 25% Albumin 100 cc for every 3 liters removed

If concern about spontaneous bacterial peritonitis or patient has kidney dysfunction, do not remove >5 liters over 24 hours

  • Remove paracentesis catheter the same day
  • Diuretic-induced complications (renal dysfunction, hyponatremia)

OR

  • Non-response to diuretics
  • Continue regular large volume paracenteses alongside general management. At each elective paracentesis do a Fluid cell count and differential and Fluid culture and sensitivity
  • Encourage compliance with sodium restriction, alcohol abstinence, monitor electrolytes, creatinine
  • The dose of non-selective beta-blockers may need to adjusted in some patients with refractory ascites
  • Non-selective beta-blocker (NSBB) use in Refractory ascites
    • In patients with Refractory ascites and (i) systolic blood pressure <90 mm Hg, or SCr >133 umol/L or (iii) sodium <130 mmol/L reduce or temporarily discontinue NSBBs
  • If paracentesis ≥ once a month:
    • Discuss alternative therapies with a Liver specialist if this hasn’t been done already (i.e. TIPS, transplantation, indwelling peritoneal catheter)
  • Q weekly weights (daily weights whole diuretic dose is being titrated): aim for up to 0.5 kg of fluid loss per day
  • Q 1-2 weekly creatinine and electrolytes as doses are being increased. Extend to Q 2-3 monthly once tolerating a stable dose
  • Reduce/Stop if: Na+ ≤ 125mmol/L or worsening kidney function, or symptomatic hypotension
  • Increase every 4-7 days as tolerated
  • Can double doses if weight loss <2 kg a week and creatinine, electrolytes are stable.
  • Adjust more cautiously once peripheral edema has cleared
  • Maximum doses are Furosemide 160 mg, Spironolactone 400 mg (see Spironolactone/Furosemide dosing ratio)
  • If there is an inadequate response to diuretics, you can use the urinary sodium to check for dietary non-compliance or resistance to diuretics.
  • The 24 hour urine or spot urine electrolytes can be used to evaluate
    • #1: Dietary non-compliance – If the Spot urine Na/K ratio is >1 OR the 24-hour urinary Na excretion is 78 mEq/day in a patient on diuretics who is not losing weight. This means the patient is sensitive to diuretics but not adherent to sodium restriction.
    • #2: Diuretic resistance – If the Spot urine Na/K ratio is 1 OR 24-hour urinary Na excretions is <78 mEq per day in a patient on maximally tolerated diuretics who is not losing weight. This mean the patient is resistant to diuretics