Treatment-ascites

• ↓ Na intake (1–2 g/d); restrict intake of free water if Na <125

• Diuretics: goal diurese ~1 L/d. Use spironolactone ± furosemide in 5:2 ratio (uptitrate as able); urine Na/K >1 implies effective natriuresis if Pt compliant w/ low-Na diet

• Avoid NSAIDs/ACEI/ARBs in cirrhosis because interfere w/ diuretic action

• Long-term albumin infusions ↓ mortality (Lancet 2018;391:2417), but not widely adopted

• If 2° to portal HTN: ↓ Na intake (<2 g/d) + diuretics; if refractory → LVP (serial) or TIPS

• If non–portal HTN related: depends on underlying cause (TB, malignancy, etc.)

• Treatment of ascites in patients with cirrhosis includes:

  • Abstinence from alcohol
  • Restricting dietary sodium
  • Treating with diuretics (algorithm 1)
  • Initial large-volume therapeutic paracentesis for patients with tense ascites

• Alcohol abstinence is important and may be improved with baclofen

• Sodium restriction to 88 mEq (2000 mg) per day is recommended, with diuretics added for most patients

• Medications such as ACE inhibitors, ARBs, and NSAIDs should be avoided or used with caution in patients with ascites

• Nonselective beta blockers may shorten survival in patients with refractory ascites and should be considered for discontinuation or avoidance.