agents in these classes are spironolactone and
furosemide, respectively. Spironolactone is more
effective than furosemide13 and can be started as
monotherapy. However, spironolactone can be
limited by hyponatremia and hyperkalemia. The
decision to use spironolactone monotherapy initially versus combination therapy with furosemide
is controversial, with differing recommendations in
clinical practice guidelines.
7, 14 Typical initial dosing
of combination therapy is 100 mg of spironolactone
and 40 mg of furosemide, with dosage increases
every 3 to 5 days as necessary, keeping the
100:40 ratio. This ratio in general maintains normo-kalemia but may need to be altered depending on
the individual patient’s response. Typical maximum
doses are 400 mg of spironolactone and 160 mg of
furosemide. For patients with tender gynecomastia, amiloride can be substituted for spironolactone,
although it is less effective.
15 Eplerenone is another
aldosterone antagonist that is more selective for
the mineralocorticoid receptor and therefore has
fewer side effects; however, it is costlier and has
not been studied in this population. Regardless
of the chosen regimen, concurrent sodium restriction is vital to the success of this approach.
Patients should be advised that nonadherence
to dietary instructions will result in ineffective
Patients with tense ascites should be treated with
large-volume paracentesis (LVP), which removes
fluid more rapidly and effectively than diuretics.
Following LVP, patients can develop paracentesis-
induced circulatory dysfunction, characterized by
reduced effective arterial blood volume and acti-
vation of the renin-angiotensin system.
17 To avoid
this complication, when more than 4 to 5 L of fluid
is removed, albumin infusion ( 6–8 g/L of fluid re-
moved) is recommended.
7 Concentrated albumin
(20%–25%) should be used to avoid the exces-
sive volume and sodium load present in dilute 5%
preparations. Albumin is superior to other colloid
agents (eg, dextran-70) for this purpose.
ing LVP, diuretic therapy should be initiated to avoid
the need for repeated LVPs.
The development of ascites is associated with
a poor prognosis, with nearly 50% mortality after
5 years.5 Therefore, patients with cirrhosis and
ascites should be considered for liver transplantation.
Patients receiving diuretics need to have intermittent blood monitoring of electrolytes and renal
function, as abnormalities in these parameters
are common. The frequency of such monitoring
is not standardized and depends on various clinical factors. Closer monitoring is definitely recommended after dose adjustments. Urine electrolyte
determination can also be helpful, particularly for
patients who are not responding clinically to diuretics. An elevated 24-hour urine sodium (>78 mEq)
is indicative of excessive sodium intake. Because
24-hour urine collection is burdensome, a spot
urine sodium/potassium ratio is a useful surrogate
for urinary sodium excretion. A ratio greater than 1
also suggests excessive sodium in the diet.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
inhibit renal prostaglandin synthesis and thereby
induce renal vasoconstriction and reduce glomerular filtration in patients with cirrhosis.
effects serve to blunt the response to diuretics and
can trigger the hepatorenal syndrome. NSAIDs
should therefore be avoided in these patients.
When analgesia is needed, acetaminophen is