According to EASL guidelines, large-volume paracentesis is the first-line therapy in patients with large ascites (grade 3), which should be completely removed in a single session. Large-volume paracentesis should be followed with plasma volume expansion to prevent postparacentesis circulatory dysfunction (PPCD). In patients undergoing large-volume paracentesis of > 5 L of ascites, plasma volume expansion should be performed by infusing albumin (8 g/L of ascites removed) because it is more effective than other plasma expanders, which are not recommended for this setting. In patients undergoing large-volume paracentesis of < 5 L of ascites, the risk of developing PPCD is low. However, these patients should still be treated with albumin because of concerns about use of alternative plasma expanders.
According to the EASL guidelines, because the development of grade 2 or 3 ascites in patients with cirrhosis is associated with reduced survival, liver transplantation should be considered as a potential treatment option.
A moderate restriction of sodium intake (80-120 mmol/d, corresponding to 4.6-6.9 g of salt) is recommended in patients with moderate, uncomplicated ascites. This is generally equivalent to a no-added-salt diet with avoidance of pre-prepared meals. Adequate nutritional education of patients on how to manage dietary sodium is also recommended. Diets with a very low sodium content (<40 mmol/d) should be avoided, because they favor diuretic-induced complications and can endanger the patient's nutritional status.
Patients with the first episode of grade 2 (moderate) ascites should receive an antimineralocorticoid (spironolactone) drug alone, starting at 100 mg/d with stepwise increases every 72 hours (in 100-mg steps) to a maximum of 400 mg/d if no response to lower doses is observed. In patients who do not respond to antimineralocorticoids, defined as a body weight reduction of less than 2 kg/wk, or in patients who develop hyperkalemia, furosemide should be added at an increasing stepwise dose from 40 mg/d to a maximum of 160 mg/d (in 40-mg steps). Patients with long-standing or recurrent ascites should be treated with a combination of an antimineralocorticoid drug and furosemide, the dose of which should be increased sequentially according to the response. Torsemide can be given in patients exhibiting a weak response to furosemide.
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Cite this: B.S. Anand. Fast Five Quiz: Liver Disease - Medscape - Aug 16, 2019.