Background: 49-year-old is admitted to the hospital for ascites with cirrhosis. Escalation of outpatient diuretics and a low-salt diet have not improved her ascites. The ascites has worsened. She has trace edema. The patient is confused.

Patient with trace lower extremity edema and ascites with cirrhosis — The patient has **trace** lower extremity edema and ascites with cirrhosis. After admission to hospital, intravenous furosemide has not markedly improved the patient’s condition. What is the next step for this patient with cirrhosis?

Intravenous furosemide (Lasix) is commenced in the hospital without effect. The ascites remains. Spironolactone is on board. The blood pressure is 98/68. The serum creatinine level has increased from 1.1 to 1.4, indicating acute kidney injury (AKI). Nephrology is consulted.

An abdominal ultrasound confirms 4 quadrant ascites. A urinalysis shows a bland urine sediment with low urine sodium excretion.

Please answer the following questions:

What is the best next step to approach the patient’s ascites?
* Start a furosemide (lasix) drip
* Add albumin
* Add the diuretic metolazone
* Stop spironolactone
* Ask interventional radiology to perform paracentesis

Ask interventional radiology to perform paracentesis to relieve the ascites.

Diuretic approach:
Explain why switching from furosemide to bumetanide (one loop diuretic to another loop diuretic) or adding a thiazide diuretic is not recommended to treat the ascites, but coadministration of a mineralocorticoid receptor antagonist such as spironolactone is standard of care in the above case study.

Switching from furosemide to bumetanide or adding a thiazide diuretic may not be effective because of potential diuretic resistance. Instead, co-administering a mineralocorticoid receptor antagonist, such as spironolactone, aligns with current guidelines for managing ascites in these patients.

Please refer to the following reference for more information: Guidelines on the management of ascites in cirrhosis, National Library of Medicine

What risk is associated with more aggressive diuresis in the setting of cirrhosis with ascites with only trace amounts of peripheral edema for this patient?

There is a risk of worsening acute kidney injury (AKI) because of worsening renal perfusion in response to increasing the diuretics.

The patient has trace edema. The blood pressure is 98/68, and the creatinine has increased. More aggressive diuresis will make matters worse here and not address the ascites. Adding more diuretics can lead to electrolyte imbalances and acute kidney injury, AKI.

The fluid that needs to be removed is in a different space, and is not responding to the current diuretic management. That is why a large volume paracentesis is preferred for her ascites at this time. This approach will remove ascitic fluid from the abdominal cavity, addressing the problematic area directly without having to increase the diuretics further, avoiding worsening acute kidney injury.

Define the potential role of albumin-assisted diuresis in managing the patient’s ascites. Is this approach going to help the patient’s symptoms?

Although it may increase urine sodium excretion slightly, it does not provide quick symptom relief and is not the preferred management step compared to large volume paracentesis.

Discussion:

➡️Learn More⬅️

Management of Refractory Ascites With Cirrhosis

Overview

A patient with cirrhosis and refractory ascites should be managed with large volume paracentesis when diuretic therapy fails.

Pathophysiology and Complications

Ascites that does not respond to diuretic therapy in cirrhosis is linked to higher mortality and acute kidney injury, AKI. The multifactorial pathophysiology involves portal hypertension, splanchnic vasodilation, porto-systemic shunts, and a decrease in effective arterial blood volume.

Treatment Approach

First steps include dietary sodium restriction and diuretics to induce negative sodium balance.
Patients unresponsive to medical therapy should undergo large volume paracentesis with albumin coadministration to prevent complications like worsening acute kidney injury. Note: the reason albumin, given with diuretics, was the wrong choice, and the better option is to perform large volume paracentesis is we are removing the ascites from the problematic compartment. So although albumin is indeed given, if large volume paracentesis were not performed, the patient would still be symptomatic, and her condition would not likely improve quickly.

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

TIPS is an invasive procedure that bypasses the cirrhotic liver to reduce intravascular pressure within the portal vein. While effective, it carries high morbidity and mortality risks and is not a first-line therapy, especially in the presence of hepatic encephalopathy.

Diuretic Therapy Considerations

Switching from furosemide to bumetanide or adding a thiazide diuretic is not likely to improve ascites.
Mineralocorticoid receptor antagonist coadministration is recommended in this setting and is part of guideline directed therapy. See inspiration below for more information.
Aggressive diuresis in the setting of trace peripheral edema could worsen acute kidney injury. In fact, we may want to decrease the patient’s loop diuretics at this time.

Inspiration: Guidelines on the management of ascites in cirrhosis, National Library of Medicine

American Society of Nephrology, Education

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