I wanted to share with you some guidelines and literature:
Chronic Outpatient Management of Ascites
- Sodium restriction (88 mmol/day [2000 mg/day])
- Diuretics (oral spironolactone with or without oral furosemide).
- Fluid restriction only if serum sodium is less than 120 to 125 mmol/L.
Chronic Outpatient Management of REFRACTORY Ascites
- Serial therapeutic paracenteses.
- Postparacentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L.
- For large-volume paracenteses, an albumin infusion of 6 to 8 g/L of fluid removed can be considered.
- Transjugular intrahepatic portasystemic stent-shunt (TIPS) may be considered in appropriately selected patients who meet criteria similar to those of published randomized trials.
Who Needs SBP Prophylaxis?
- Anyone who has had SBP before.
- Anyone with cirrhosis admitted with a variceal bleed. See the NEJM paper
- Anyone with cirrhosis, ascites ascitic protein less than 1.5, creatinine greater than 106 mmol/L OR BUN greater than 8.9 mmol/L), serum Na less than 130, MELD greater than 9 points with bilirubin greater than 3 mg/dL.
One question that came up was whether prophylaxis should be daily or intermittently. Both regiments have been shown to be of benefit in clinical trials, but there is concern that intermittent dosing will lead to bacterial resistance and therefore the preferred regimen according to the AASLD is daily.
Renal Failure in Ascites
Erik mentioned using albumin in patients with SBP. The major evidence supporting this practice is from an article published in the NEJM in 1999 which randomized patients with SBP to either antibiotics alone or antibiotics with albumin. The investigators found a statistically significant reduction in renal dsyfunction and mortality with this regimen.
There was aslo a recent review article on renal failure and cirrhosis in the NEJM.
See the AASLD Guidelines for more information on the management of ascites.
