Page 6 - 02- Ascites (Cổ chướng)

mEq/L, renal impairment with creatinine rise of 100% to more than 2.0
Treatment:
– Ensure compliance with dietary sodium restriction using 24-hour urine sodium excretion:
Discontinue diuretics if urinary sodium excretion under diuretic therapy is less than 30
mmol/day.
Therapeutic paracentesis or serial large-volume paracentesis (LVP) (see “Surgery/Other
Procedures”).
IV furosemide reduces eGFR dramatically in ascitic patients and is better avoided.

Second Line
Midodrine 7.5 mg TID can be used for refractory ascites or hypotensive patients, it was found
to improve response to diuretics, improve hyponatremia, mean arterial pressure, and may
improve survival (1)[B]. Titrate to blood pressure response.
Alternatives to spironolactone: amiloride up to 40 mg/day; triamterene up to 200 mg/day in
divided doses (1)[C]
Alternatives to furosemide: torsemide up to 100 mg/day; bumetanide up to 4 mg/day (1)[C]
Vaptans may have a beneficial effect on hyponatremia and ascites, but routine use in ascites is
not yet supported. FDA has recommended to avoid use in chronic liver disease due to potential
to induce serious liver injury (2)[A].
ISSUES FOR REFERRAL
Liver transplant is the definitive treatment for portal hypertension. Consider referral for
transplant in patients with decompensated liver disease, whether or not ascites is
present/controlled (1)[B].

SURGERY/OTHER PROCEDURES
Therapeutic paracentesis
– Initial therapy if tense ascites is present (1)[C]
– Serial (generally every 2 weeks) paracenteses can be used as second line after diuretics in
patients with elevated portal pressures.
– Complications: infection, hemodynamic collapse, acute renal failure
– Similar complication rate as diuretics
– Replace albumin when removing >5 L of ascites: 5.5 to 8.0 g albumin for each liter
removed. Albumin replacement decreases renal dysfunction, postparacentesis
hyponatremia, and overall morbidity; likely not needed for malignant ascites
– Continue diuretics at 50% of the previous dose if transitioning to serial paracentesis in
patients failing diuretic monotherapy.
Transjugular intrahepatic portosystemic shunt (TIPS)
– Only for patients with elevated portal pressures with refractory ascites
– Fluoroscopically placed conduit from portal to hepatic vein for intractable ascites
At time of placement, portal pressure should drop ≥20 mm Hg (or to <12 mm Hg), and
ascites should be controllable with diuretics.
Yearly US to confirm shunt function
4 weeks after TIPS, urinary sodium and serum creatinine improve significantly and can
normalize after 6 to 12 months in combination with diuretics. Shunt dilation and/or
replacement may be required after 2 years.
TIPS is superior to paracentesis for controlling ascites; no difference in mortality