Diuresis in the ascitic patient: a randomized controlled trial of three regimens

Optimization of Kidney Health in Liver Transplant Candidates: Pretransplant Considerations and Modalities

Patients with decompensated end-stage liver disease (ESLD) are at increased risk for mortality, and only liver transplantation (LT) offers meaningful hope for survival. These patients are at risk for kidney dysfunction through the continuum of care for ESLD including LT. We discuss the role of accurate estimation and measurement of baseline glomerular filtration rate in assessment of kidney dysfunction among those with ESLD. Optimizing kidney function is a vital goal in the management of these patients before LT. In this review, we summarize salient aspects of assessing and optimizing kidney function in this patient population. Precipitating factors and different causes of acute kidney injury are discussed, including hepatorenal syndrome. We further review treatment options for acute kidney injury including volume management. The role of vasopressor therapy, renal replacement therapy, and transjugular intrahepatic portosystemic shunting are discussed.

Guidelines on the management of ascites in cirrhosis

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.

Treatment for ascites in adults with decompensated liver cirrhosis: a network meta-analysis

BACKGROUND

Approximately 20% of people with cirrhosis develop ascites. Several different treatments are available; including, among others, paracentesis plus fluid replacement, transjugular intrahepatic portosystemic shunts, aldosterone antagonists, and loop diuretics. However, there is uncertainty surrounding their relative efficacy.

OBJECTIVES

To compare the benefits and harms of different treatments for ascites in people with decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for ascites according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until May 2019 to identify randomised clinical trials in people with cirrhosis and ascites.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and ascites. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included a total of 49 randomised clinical trials (3521 participants) in the review. Forty-two trials (2870 participants) were included in one or more outcomes in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies, without other features of decompensation, having mainly grade 3 (severe), recurrent, or refractory ascites. The follow-up in the trials ranged from 0.1 to 84 months. All the trials were at high risk of bias, and the overall certainty of evidence was low or very low. Approximately 36.8% of participants who received paracentesis plus fluid replacement (reference group, the current standard treatment) died within 11 months. There was no evidence of differences in mortality, adverse events, or liver transplantation in people receiving different interventions compared to paracentesis plus fluid replacement (very low-certainty evidence). Resolution of ascites at maximal follow-up was higher with transjugular intrahepatic portosystemic shunt (HR 9.44; 95% CrI 1.93 to 62.68) and adding aldosterone antagonists to paracentesis plus fluid replacement (HR 30.63; 95% CrI 5.06 to 692.98) compared to paracentesis plus fluid replacement (very low-certainty evidence). Aldosterone antagonists plus loop diuretics had a higher rate of other decompensation events such as hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding compared to paracentesis plus fluid replacement (rate ratio 2.04; 95% CrI 1.37 to 3.10) (very low-certainty evidence). None of the trials using paracentesis plus fluid replacement reported health-related quality of life or symptomatic recovery from ascites.

FUNDING

the source of funding for four trials were industries which would benefit from the results of the study; 24 trials received no additional funding or were funded by neutral organisations; and the source of funding for the remaining 21 trials was unclear.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence, there is considerable uncertainty about whether interventions for ascites in people with decompensated liver cirrhosis decrease mortality, adverse events, or liver transplantation compared to paracentesis plus fluid replacement in people with decompensated liver cirrhosis and ascites. Based on very low-certainty evidence, transjugular intrahepatic portosystemic shunt and adding aldosterone antagonists to paracentesis plus fluid replacement may increase the resolution of ascites compared to paracentesis plus fluid replacement. Based on very low-certainty evidence, aldosterone antagonists plus loop diuretics may increase the decompensation rate compared to paracentesis plus fluid replacement.

Portal Hypertension and Related Complications: Diagnosis and Management

Portal hypertension is a major complication of cirrhosis, and its consequences, including ascites, esophageal varices, hepatic encephalopathy, and hepatorenal syndrome, lead to substantial morbidity and mortality. The past several decades have seen major improvements in the clinical management of complications of portal hypertension, resulting in substantial gains in patient outcomes. However, important challenges remain. This review focuses on the pathophysiology and diagnosis of portal hypertension and discusses general approaches in the management of patients with ascites as a result of portal hypertension.

Transjugular Intrahepatic Portosystemic Shunt Placement for Refractory Ascites: Review and Update of the Literature

Ascites is the most common complication of cirrhosis, impairs quality of life, and carries a poor prognosis. Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated therapy for refractory ascites and is superior at reducing the accumulation of fluid compared with paracentesis. More recent evidence has shown that TIPS also provides an improved transplant-free survival compared with paracentesis. To maximize the clinical efficacy and survival advantage, proper patient selection is crucial. While current guidelines recommend that elective TIPS for ascites should be performed only in patients with MELD ≤ 18, recent literature suggests that elective TIPS safely and effectively controls ascites and potentially provides a survival advantage in patients with higher MELD scores (≤ 24). The evolution of these findings likely represents the combination of improved medical management of cirrhotic patients, improved devices, and a better knowledge of selection criteria for potential TIPS patients. This article will review the pathophysiology and management of ascites, with a focus on the evidence supporting TIPS placement for refractory ascites.

To salt or not to salt?-That is the question in cirrhosis

Ascites is the most common complication of patients with cirrhosis, resulting from portal hypertension and vasodilatation. It is associated with an increased risk for the development of hyponatraemia and renal failure and has a high mortality rate of 20% per year. The development of ascites represents a baleful sign in the course of disease in cirrhosis. To prevent complications of cirrhosis and improve quality of life, an effective management of ascites is pivotal. Combined salt restriction and diuretic therapy is recommended as first-line therapy in numerous clinical practice guidelines. In contrast, there has been a debate on whether a strict salt-restricted diet for cirrhosis patients should be used at all since salt restriction may increase the risk for malnutrition which in turn may negatively impact on quality of life and survival. This review aims to summarize the current pros and cons regarding salt restriction in patients with cirrhosis and proposes the importance of achieving a sodium balance throughout different stages of cirrhosis.

The Outcome of Thoracentesis versus Chest Tube Placement for Hepatic Hydrothorax in Patients with Cirrhosis: A Nationwide Analysis of the National Inpatient Sample

There are only a few studies with a small sample size of patients that have compared the risks of using chest tubes versus thoracentesis in hepatic hydrothorax. It has been shown that many complications may arise secondary to chest tube placement and is associated with increased morbidity and mortality. In this retrospective study, patients with cirrhosis were identified from the 2009 National Inpatient Sample by using ICD-9 codes; we evaluated the risk of chest tube versus thoracentesis in a largest population with hepatic hydrothorax to date to measure the mortality and the length of stay. A total of 140,573 patients with liver cirrhosis were identified. Of this, 1981 patients had a hepatic hydrothorax and ended up with either thoracentesis (1776) or chest tube (205). The mortality in those who received a chest tube was two times higher than that in thoracentesis group with a P value of ≤0.001 (CI 1.43–312). In addition, the length of hospital stay of the chest tube group was longer than that of the thoracentesis subset (7.2 days versus 3.8 days, resp.). We concluded that chest tube placement has two times higher mortality rate and longer hospital length of stay when compared to patients who underwent thoracentesis.

Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III)

The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.

Spironolactone

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

Diuretic Resistance

Diuretic resistance is defined as a failure to achieve the therapeutically desired reduction in edema despite a full dose of diuretic. The causes of diuretic resistance include poor adherence to drug therapy or dietary sodium restriction, pharmacokinetic issues, and compensatory increases in sodium reabsorption in nephron sites that are not blocked by the diuretic. To illustrate the pathophysiology and management of diuretic resistance, we describe a patient with nephrotic syndrome. This patient presented with generalized pitting edema and weight gain despite the use of oral loop diuretics. Nephrotic syndrome may cause mucosal edema of the intestine, limiting the absorption of diuretics. In addition, the patient's kidney function had deteriorated, impairing the tubular secretion of diuretics. He was admitted for intravenous loop diuretic treatment. However, this was ineffective, likely due to compensatory sodium reabsorption by other tubular segments. The combination of loop diuretics with triamterene, a blocker of the epithelial sodium channel, effectively reduced body weight and edema. Recent data suggest that plasmin in nephrotic urine can activate the epithelial sodium channel, potentially contributing to the diuretic resistance in this patient. This case is used to illustrate and review the mechanisms of, and possible interventions for, diuretic resistance.

Furosemide

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available on www.palliativedrugs.com. Country-specific books (Hospice and Palliative Care Formulary USA, and Palliative Care Formulary, British and Canadian editions) are also available and can be ordered from www.palliativedrugs.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).

The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations

Several pathogenic processes have been implicated in the development of abdominal ascites. Portal hypertension, most usually in the context of liver cirrhosis, can explain about 75% of the cases, whereas infective, inflammatory and infiltrative aetiologies can account for the rest. In this article, we discuss the consensus best practice as published by three professional bodies for the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). The aim of this study was to compare available clinical guidelines and identify areas of agreement and conflict. We carried out a review of the guidance documentation published by three expert bodies including the British Society of Gastroenterology, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD), as well as a wider literature search for ascites, SBP and HRS. Abdominal ultrasonography, diagnostic paracentesis and ascitic fluid cultures are recommended by all three guidelines, especially when there is strong clinical suspicion for infection. EASL and AASLD advocate the use of ascitic amylase and mycobacterial cultures/PCR when there is strong suspicion for tuberculosis and pancreatitis, respectively. Ascitic cytology can be useful when cancer is suspected and has a good diagnostic yield if performed correctly. EASL supports the use of urinary electrolytes for all patients; however, the British Society of Gastroenterology and AASLD only recommend their use for therapy monitoring. All three societies recommend cefotaxime as the antibiotic of choice for SBP and large-volume paracentesis for the management of ascites greater than 5 l in volume. For HRS, cautious diuresis, volume expansion with albumin and the use of vasoactive drugs are recommended. There appears to be good concordance between recommendations by the European, American and British guidelines for the management of ascites and the possible complications arising from it.

Mineralocorticoid receptor antagonists as diuretics: Can congestive heart failure learn from liver failure?

Despite significant improvements in diagnosis, understanding the pathophysiology and management of the patients with acute decompensated heart failure (ADHF), diuretic resistance, yet to be clearly defined, is a major hurdle. Secondary hyperaldosteronism is a pivotal factor in pathogenesis of sodium retention, refractory congestion in heart failure (HF) as well as diuretic resistance. In patients with decompensated cirrhosis who suffer from ascites, similar pathophysiological complications have been recognized. Administration of natriuretic doses of mineralocorticoid receptor antagonists (MRAs) has been well established in management of cirrhotic patients. However, this strategy in patients with ADHF has not been well studied. This article will discuss the potential use of natriuretic doses of MRAs to overcome the secondary hyperaldosteronism as an alternative diuretic regimen in patients with HF.

Response to pathological processes in the peritoneal cavity--sepsis, tumours, adhesions, and ascites

The peritoneum is one of the commonest sites for pathological processes in pediatric surgery. Its response to pathological processes is characterized by an inflammatory reaction with specific pathways depending on the type of injury or peritoneal process involved. This review discusses the current understanding of peritoneal inflammation, adhesion formation, intra-abdominal sepsis, peritoneal metastasis, and ascites and briefly reviews new therapeutic strategies to treat or prevent these pathological entities. Recent studies have improved the understanding of peritoneal responses, resulting in possible new targets for prevention and therapy.

Management of Complications of End-Stage Liver Disease in the Intensive Care Unit

The management of critically ill patients with end-stage liver disease can be challenging due to the vulnerability of this population and the wide-ranging complications of the disease. This review proposes an approach based on the major organ systems affected, to provide a framework for managing the most common complications. Although considerable practice variation exists, a focus on the evidence behind the most common practices will ensure the development of the optimal skillset to appropriately manage this disease.

Continuous furosemide infusion in the management of ascites

BACKGROUND

The current therapy for patients hospitalized with ascites requires titration of oral diuretics and often needs several days. A faster method for predicting the response to a given dose of diuretic may allow this process to be completed more rapidly.

AIM

The objective of this study was to describe the short-term safety and efficacy of a diuretic infusion to predict net sodium excretion in patients with cirrhosis, ascites, and edema using a fractional excretion of sodium (FENa) of 1% or greater as the target.

METHODS

We conducted a retrospective case series of patients admitted for management of ascites who received intravenous furosemide by continuous infusion in ascites management. Patients were stratified depending on whether they had edema or received an intravenous bolus of furosemide or a large-volume paracentesis. The primary outcome was the proportion of patients achieving a FENa of 1% or greater during the infusion. Secondary outcomes included development of electrolyte abnormalities or acute kidney injury during or immediately following the infusion and natriuresis on titrated oral furosemide.

RESULTS

Forty-seven patients meeting criteria were identified from 721 patients seen in consultation. Ten of the patients had edema and received neither bolus intravenous diuretic therapy nor therapeutic paracentesis; all 10 achieved a FENa of 1% or greater. One patient had transient hypokalemia. Of 37 patients who either had no edema or received additional treatment options, all but 6 patients achieved a FENa of 1% or greater. Transient complications in 31 patients with natriuresis included hyponatremia (n = 1), hypokalemia (n = 5), and acute kidney injury (n = 3). Twenty-four-hour urine sodium averaged more than 4 g/d on the titrated oral furosemide regimen in 19 patients completing the collection.

CONCLUSIONS

Use of a short continuous furosemide infusion can achieve a FENa of 1% or greater in patients with cirrhotic ascites and may be safe and efficacious for diuresis, meriting further study.

Contribution of diuretic therapy with human serum albumin to the management of ascites in patients with advanced liver cirrhosis: A prospective cohort study

The number of available studies on the role of human serum albumin (HSA) in the treatment of cirrhotic ascites is currently limited. In this study, we aimed to investigated the parameters associated with diuretic therapy with HSA in patients with advanced cirrhotic ascites. The patient inclusion criteria were cirrhotic ascites and a serum albumin (Alb) concentration of <3.5 g/dl. A total of 49 patients registered and 38 patients were ultimately included in this study. The enrolled patients were mainly treated with oral spironolactone and furosemide, which were not specified; the HSA amount was also not specified, although the administration period was set to a maximum of 7 days. Our results demonstrated that the administration of HSA significantly increased the serum levels of Alb [0.97 g/dl; two-sided 95% confidence interval (CI): 0.83-1.11 g/dl] and decreased body weight (-2.24 kg; 95% CI: -3.06 to -1.43 kg), hematocrit ratio (0.96; 95% CI: 0.94-0.98) and plasma renin concentration (day 4; geometric mean fold change, -0.1528; 95% CI: -0.2510 to -0.0545; log-transformed data) in patients with advanced cirrhotic ascites. The observed weight loss was found to be correlated with the total amount of HSA administered (P=0.0012), as indicated by the results of the multiple linear regression analysis. In conclusion, this study confirmed the efficacy of HSA in patients with advanced cirrhotic ascites.

Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers

Cirrhosis affects millions of people throughout the world. Two of the most serious complications of liver cirrhosis are ascites and spontaneous bacterial peritonitis (SBP). The development of ascites is related to the severity of portal hypertension and is an indicator of increased mortality. Although sodium restriction and diuretic therapy have proven effective, some patients may not respond appropriately or develop adverse reactions to diuretic therapy. In such cases, interventions such as transjugular intrahepatic portosystemic shunt (TIPS) placement are warranted. SBP is a complication of ascites that confers a very high mortality rate. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. Initiation of prophylaxis in SBP remains controversial. Given the burden of liver cirrhosis on the health care system, ascites and SBP will continue to provide challenges for the primary care provider, hospitalist, internist, and gastroenterologist alike.

Multidisciplinary approach for HCC patients: hepatology for the oncologists

Hepatocellular carcinoma (HCC) is a complex and heterogeneous disease, often associated with underlying conditions, like cirrhosis or other relevant co-morbidities that worsen the prognosis and make the clinical management more challenging. Current recommendations emphasize the importance of a multidisciplinary approach for the management of HCC patients and stress the crucial role of careful prevention and the management of cirrhosis-associated complications. This article discusses the importance of a multidisciplinary approach in the treatment of HCC patients. Current recommendations for the treatment of cirrhotic patients with HCC are also reviewed.

Cirrhotic ascites review: Pathophysiology, diagnosis and management

Ascites is a pathologic accumulation of peritoneal fluidcommonly observed in decompensated cirrhotic states.Its causes are multi-factorial, but principally involve significant volume and hormonal dysregulation in the setting of portal hypertension. The diagnosis of ascites is considered in cirrhotic patients given a constellation of clinical and laboratory findings, and ultimately confirmed, with insight into etiology, by imaging and paracentesis procedures. Treatment for ascites is multi-modal including dietary sodium restriction, pharmacologic therapies, diagnostic and therapeutic paracentesis, and in certain cases transjugular intra-hepatic portosystemic shunt. Ascites is associated with numerous complications including spontaneous bacterial peritonitis, hepato-hydrothorax and hepatorenal syndrome. Given the complex nature of ascites and associatedcomplications, it is not surprising that it heralds increased morbidity and mortality in cirrhotic patients and increased cost-utilization upon the health-care system. This review will detail the pathophysiology of cirrhotic ascites, common complications derived from it, and pertinent treatment modalities.

Pharmacotherapy for pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a disabling, progressive disease. The past decade has seen an explosion in the available therapies for the management of PAH. Choosing appropriate pharmacotherapy can be a daunting task for the practitioner, as no head-to-head comparisons between drugs have been published. This article aims to assist the practitioner in developing an evidence-based, rational pharmacologic treatment algorithm for the management of patients with PAH. Currently approved pharmacotherapy and the pivotal trials that led to approval for the respective agents are reviewed. Common dilemmas in the treatment of PAH for which strong evidence is lacking are discussed.

Intravenous high-dose furosemide and hypertonic saline solutions for refractory heart failure and ascites

Several studies have shown the efficacy of hypertonic saline solution infusion in conditions in which regional organ blood flow is impaired. Our group has shown that treatment of patients with diuretic-resistant heart failure with high-dose furosemide plus hypertonic saline is effective and well tolerated, improving symptoms of congestion, reducing plasma levels of markers of neurohormonal and inflammatory activation, decreasing hospital readmission rates, and reducing long-term mortality. The same regimen was shown to be better than repeated paracentesis in patients with cirrhosis and refractory ascites, yielding better control of ascites, pleural effusions, and/or leg edema without an increase of common adverse effects linked to high-dose furosemide such as hepatic encephalopathy.

Diagnosis and therapy of ascites in liver cirrhosis

Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm³ and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.

Medical management of ascites

INTRODUCTION

Ascites is a common complication of advanced cirrhosis that has a significant negative impact on survival. This review updates the reader on the medical management of ascites.

AREAS COVERED

This review explores the pathophysiology of ascites formation in cirrhosis; the current mainstays of medical management (treating the underlying cause of cirrhosis, avoiding nephrotoxic agents, sodium restriction, and combination diuretic therapy); potential novel agents, such as vasoconstrictors and vaptans; and albumin infusions. The literature research covers all aspects of medical management of ascites from the English literature, concentrating on publications from the past 10 years. It provides a thorough understanding of how the correction of pathophysiology of ascites formation helps to improve ascites; knowledge on the monitoring of patients with cirrhosis and ascites receiving medical management, and on prophylaxis against potentially life-threatening complication such as spontaneous bacterial peritonitis; and potential new treatments for ascites.

EXPERT OPINION

Management of patients with cirrhosis and ascites requires careful attention to fluid and electrolyte balance and avoidance of complications. Recognition of refractory ascites allows for the use of second-line treatments. All patients with cirrhosis and ascites should be considered for liver transplantation.

Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program

Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.

Pharmacologic approaches for volume excess in acute kidney injury (AKI)

Volume management is an integral component of the care of patients with acute kidney injury (AKI). Considerable controversy exists regarding the use of pharmacological agents for volume management. Although overt fluid overload is often seen in AKI and may prompt attention for the use of diuretics, often these agents are used in the absence of fluid retention. Over the last decade several new agents have become available for volume removal. We reviewed the literature on this topic and addressed four key questions for the appropriate utilization of these agents. These include the drug targets and mechanism of action of available agents; clinical goals and criteria for timing of intervention; adaptation of therapy for specific clinical settings and measures required for monitoring effectiveness and patient safety. This report details our current knowledge in this area, provides evidence-based clinical practice recommendations where appropriate, and formulates a research agenda to address unanswered questions.

Advances in critical care management of hepatic failure and insufficiency

BACKGROUND

Chronic liver disease is becoming an increasingly frequent diagnosis for patients in the intensive care setting with such diagnoses as symptomatic ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, or fulminant hepatic failure.

OBJECTIVE

To review frequent diagnoses for patients with chronic liver disease admitted to the intensive care unit and discuss current concepts in management and investigational modalities.

RESULTS

Patients with new-onset ascites in the intensive care setting should undergo immediate ultrasound to rule out acute thrombosis. A transjugular intrahepatic portosystemic shunt is indicated when control of the refractory ascites or hepatic hydrothorax is required. In patients with hepatorenal syndrome, hemodialysis can be used as a bridge to liver transplantation. Otherwise, hepatorenal syndrome carries a high mortality. When hepatic encephalopathy is present, a precipitating cause should be sought and treated, if identified. Although bioartificial support systems are under active investigation, standard treatment for hepatic encephalopathy is lactulose and alteration of gut flora. Patients with fulminant hepatic failure should be stabilized and transferred to the intensive care unit of a liver transplant center and supported with appropriate airway management, close neurologic evaluation, glucose monitoring, and correction of coagulopathy when there is overt bleeding or an invasive procedure is planned. Intracranial pressure monitoring is recommended to maintain an adequate cerebral perfusion pressure of >60 mm Hg.

CONCLUSION

Review of the literature demonstrates that certain critically ill patients with chronic liver disease may benefit from invasive modalities such as transjugular intrahepatic portosystemic shunting, hemodialysis, and in some cases, liver transplantation, which may be offered only at tertiary care centers.

Palliative care for patients with end-stage liver disease ineligible for liver transplantation

The proportion of patients with ESLD who will be managed without liver transplantation will increase in the near future, largely as a result of the increasing age of the population. Patients with ESLD are subject to many physical and psychosocial symptoms that negatively affect health-related quality of life. Sleep quality should be maximized by controlling pruritus and leg cramps. Many frequently used therapies are not supported by a strong evidence base. Advance directives should be addressed with all patients with ESLD, preferably in the outpatient setting before an acute deterioration. Medicare provides a hospice benefit for patients with ESLD, and referral to a hospice is appropriate for patients with an expected survival of 6 months or less.

Management of cirrhotic ascites: physiological basis of diuretic action

Ascites is a significant complication of cirrhosis that occurs in approximately 50% of patients. The mortality rate is high in patients with cirrhosis and ascites. Conventional interventions rest with dietary sodium restriction, diuretic use, large-volume paracentesis, peritoneovenous shunts and transjugular intrahepatic portosystemic shunts. The mainstay of therapy, however, is the judicious use of diuretics. This article reviews the physiological basis of diuretic use in patients with cirrhosis and ascites, as well as recent concepts on the pathogenesis of ascites formation. Through a better understanding of the pathophysiology of ascites formation and the mechanism of action of diuretics, improved extracellular fluid balance can be achieved in these patients.

Management of ascites in cirrhosis

Onset of ascites in cirrhosis of the liver is associated with worsened quality of life, increased risk of spontaneous bacterial peritonitis, and renal failure. Portal hypertension produces splanchnic vasodilation that triggers the cascade of events leading to release of Na retentive vasoconstrictor hormones. Management of ascites caused by cirrhosis is based on improving the Na excretion with diuretics and Na restriction in diet. Refractory ascites and hepatorenal syndrome are the complications of ascites that carry a very high mortality. Large volume paracentesis and transjugular intrahepatic porto-systemic shunts are useful in managing patients with refractory ascites. Liver transplant is the only way to improve survival in ascites caused by cirrhosis.

Treatment of ascites

Ascites is the most common complication of cirrhosis and occurs in more than half of all patients with cirrhosis. The development of ascites indicates progression of the underlying cirrhosis and is associated with a 50% 2-year survival rate. Conventional therapies used for the treatment of ascites include sodium restriction (<88 mmol/d), diuretics, and large volume paracentesis (LVP) (>5 L). The most effective diuretic combination is that of a potassium-sparing, distal-acting diuretic (eg, spironolactone) with a loop diuretic (eg, furosemide). LVP provides rapid resolution of symptoms with minimal complications and is well tolerated by most patients. Post-paracentesis circulatory dysfunction (PPCD) may occur after LVP and is characterized by hyponatremia, azotemia, and an increase in plasma renin activity. PPCD is associated with an increased mortality and may be prevented by administration of albumin intravenously (6 to 8 g/L of ascites removed) along with LVP. The development of either diuretic-resistant or diuretic-intractable ascites occurs in approximately 5% to 10 % of all cases of ascites. This is a poor prognostic sign, as 50% of such patients die within 6 months of its development. The only definitive therapy for refractory ascites with cirrhosis is orthotopic liver transplantation. The other options that are available include LVP, peritoneovenous shunts, and transjugular intrahepatic portosystemic shunts (TIPS). The TIPS procedure has not been shown to have any influence on survival in patients with cirrhosis and refractory ascites, and TIPS is contraindicated in patients who have advanced liver failure because it can hasten death in such individuals. Peritoneovenous shunts are associated with a high incidence of complications and frequent occlusion. They are, therefore, rarely used for refractory ascites. Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites. It may precipitate hepatorenal syndrome. The overall mortality rate from an episode of SBP is approximately 20%. Following an episode of SBP, the 1-year mortality rate approaches 70%. Hospitalized patients should be treated with intravenous third-generation cephalosporins (eg, cefotaxime), and patients at risk should receive prophylaxis with either orally administered quinolones (eg, norfloxacin) or cotrimoxazole.

Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A randomized comparative study of efficacy and safety

BACKGROUND/AIMS

The most rational treatment of moderate ascites is spironolactone alone or in combination with furosemide. However, it is unknown which of these two treatment schedules is preferable.

METHODS

One hundred nonazotemic cirrhotic patients with moderate ascites were randomly assigned to be treated with spironolactone and furosemide (Group 1: 50 patients) or with spironolactone alone (Group 2: 50 patients). If no response was obtained, the doses of diuretics were increased up to 400 mg/day of spironolactone and 160 mg/day of furosemide. In patients of group 2 not responding to 400 mg/day of spironolactone, furosemide was added. In cases with an excessive response, the dosage of diuretics was reduced.

RESULTS

The response rate (98% in Group 1 vs. 94% in Group 2), the rapidity of ascites mobilization and the incidence of complications induced by diuretic therapy was similar in both groups. The need to reduce the diuretic dosage was significantly higher in Group 1 than Group 2 (68% vs. 34%; P=0.002).

CONCLUSIONS

In the treatment of moderate ascites, spironolactone alone seems to be as safe and effective as spironolactone associated with furosemide. Since spironolactone alone requires less dose adjustment, it would be more suitable for treating ascites on an outpatient basis.

The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club

Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well-being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis.

Pathophysiology and management of pediatric ascites

Ascites accumulation is the product of a complex process involving hepatic, renal, systemic, hemodynamic, and neurohormonal factors. The main pathophysiologic theories of ascites formation include the "underfill," "overflow," and peripheral arterial vasodilation hypotheses. These theories are not necessarily mutually exclusive and are linked at some level by a common pathophysiologic thread: The body senses a decreased effective arterial blood volume, leading to stimulation of the sympathetic nervous system, arginine-vasopressin feedback loops, and the renin-angiotensin-aldosterone system. Cornerstones of ascites management include dietary sodium restriction and diuretics. Spironolactone is generally tried initially, with furosemide added if clinical response is suboptimal. More refractory patients require large-volume paracentesis (LVP) accompanied by volume expansion with albumin. Placement of a transjugular intrahepatic portosystemic shunt is reserved for individuals with compensated liver function who require very frequent sessions of LVP. Peritoneovenous shunts are not used in contemporary ascites management. Liver transplantation remains the definitive therapy for refractory ascites. Although treatment of ascites fails to improve survival, it benefits quality of life and limits the development of such complications as spontaneous bacterial peritonitis.

Monitoring of transtubular potassium gradient in the diuretic management of patients with cirrhosis and ascites

BACKGROUND/AIMS

Aldosterone antagonists are the diuretics of first choice in the treatment of cirrhotic ascites. However, there is still no reliable clinical parameter to evaluate their efficacy. Transtubular potassium gradient (TTKG), the accurate indicator of aldosterone bioactivity, may serve as a guide for the proper use of the aldosterone antagonists.

METHODS

In 23 patients with cirrhotic ascites, the daily administered initial dosage of 100 mg of spironolactone was increased by 100 mg/day at intervals of 5 days until either diuresis commenced or TTKG fell below 3.0, the value indicating complete blockade of aldosterone bioactivity. For the non-responders with TTKG lower than 3.0, furosemide was given in addition to spironolactone.

RESULTS

Basal TTKG correlated significantly with plasma aldosterone concentration (r = 0.60, P = 0.002). Spironolactone induced the decrease of TTKG in 20 patients, from 5.3 +/- 0.5 to 2.9 +/- 0.2 (mean +/- SE, P < 0.001). A TTKG value of 3.0 could classify seven patients, who did not respond to low dose spironolactone, into two distinct groups at that time, indicating different further diuretic regimen. All patients achieved diuretic responses without complication by this TTKG-guided modification of diuretics.

CONCLUSIONS

TTKG may be a suitable guide for the diuretic management of cirrhotic ascites by accurately reflecting the effect of aldosterone antagonists.

Update on ascites and hepatorenal syndrome

Ascites is the most common complication occurring during liver cirrhosis. Even if a significant decrease in renal clearance may be observed in the first step of chronic active liver disease, renal impairment, at times complicated by the typical signs of hepatorenal syndrome, occurs only in patients with ascites, especially when tense and refractory. Experimental and clinical data seem to suggest a primary sodium and water retention in the pathogenesis of ascites, in the presence of an intrahepatic increase of hydrostatic pressure, which, by itself, physiologically occurs during digestion. Abnormal sodium and water handling leads to plasma volume expansion, followed by decreased peripheral vascular resistance and increased cardiac output. This second step is in agreement with the peripheral arterial vasodilation hypothesis, depicted by an increase in total blood volume, but with a decreased effective arterial blood volume. This discrepancy leads to the activation of the sympathetic nervous and renin-angiotensin-aldosterone systems associated with the progressive activation of the renal autacoid systems, especially, that of the arachidonic acid. During advanced cirrhosis, renal impairment becomes more sustained and renal autacoid vasodilating substances are less available, possibly due to a progressive exhaustion of these systems. At the same time ascites becomes refractory inasmuch as it is no longer responsive to diuretic treatment. Various pathogenetic mechanisms leading to refractory ascites are mentioned. Finally, several treatment approaches to overcome the reduced effectiveness of diuretic therapy are cited. Paracentesis, together with simultaneous administration of human albumin or other plasma expanders is the main common approach to treat refractory ascites and to avoid a further decrease in renal failure. Other effective tools are: administration of terlipressin together with albumin, implantation of the Le Veen shunt, surgical porto-systemic shunting or transjugular intrahepatic portosystemic stent-shunt, or orthotopic liver transplantation, according to the conditions of the individual patient.

Ascites

Ascites is the most common presentation of decompensated cirrhosis, and its development heralds a poor prognosis, with a 50% 2-year survival rate. Effective first-line therapy for ascites includes sodium restriction (2 g/d), use of diuretics, and large-volume paracentesis (LVP). Ideally, a combination of a loop-acting diuretic (eg, furosemide) and a distal-acting diuretic (eg, spironolactone) is used. LVP has the advantage of producing immediate relief from ascites and its associated symptoms. When 5 L or more ascitic fluid is removed, albumin (6 to 8 g per liter of fluid removed) should be administered intravenously to minimize hemodynamic and renal dysfunction. The development of refractory ascites is particularly ominous, and 50% of such patients die within 6 months of its development. Liver transplantation is the only effective therapy for patients with refractory ascites associated with cirrhosis; unfortunately, this therapy is not available for many of those with refractory ascites. Other therapies that are available include LVP, peritoneovenous shunts, and transjugular intrahepatic portasystemic shunts (TIPS). LVP alleviates ascites rapidly, but ascites recurs universally, requiring repeated hospitalizations and paracenteses and decreasing patient quality of life. Peritoneovenous shunts rarely are used due to their high complication rate and tendency to become occluded. Recently, the use of TIPS has been shown to be an effective therapy for patients with refractory ascites. It is most effective when liver function is relatively well preserved. On the other hand, TIPS may hasten death in those with advanced liver failure. TIPS has not been shown to have a clear-cut beneficial effect on survival in patients with refractory ascites. Spontaneous bacterial peritonitis is the most common complication of ascites and is associated with a worsening hyperdynamic circulation and a mortality rate of approximately 20%. Following an episode of spontaneous bacterial peritonitis, the 1-year mortality rate approaches 70%. Patients at risk should be considered for prophylaxis with an orally administered quinolone (eg, norfloxacin). Alternatives include trimethoprim/sulfamethoxazole. Active spontaneous bacterial peritonitis should be treated with an intravenously administered third-generation cephalosporins (eg, cefotaxime) in most circumstances.

Clinical management of ascites and its complications

Development of ascites is a poor prognostic sign with a 1 year mortality rate of up to 50%. Cirrhotic patients who develop ascites should therefore be evaluated for liver transplantation. Even though current therapies of ascites are not associated with a survival benefit, the elimination of ascites will improve quality of life and prevent the development of lethal complications such as SBP and HRS. Therapy of ascites should be directed at correcting the pathophysiologic abnormalities that lead to ascites formation, namely sodium retention, reduced effective arterial blood volume, and sinusoidal hypertension.

Predictive factors influencing the therapeutic response to diuretic treatment of ascites in nonazotemic cirrhotic patients

BACKGROUND

A low-sodium diet and diuretics, although widely used, are not always the most satisfactory therapy for treatment of ascites in nonazotemic patients with liver cirrhosis. The objective of this investigation was to analyze various predictive factors influencing the therapeutic response to diuretic treatment of ascites in these patients.

METHODS

Twenty-seven patients with nonazotemic liver cirrhosis and ascites were initially treated with spironolactone, 200 mg/day. If no response was observed, furosemide was added at 40-120 mg/day. Before and during the diuretic therapy 30 clinical and laboratory variables were investigated as possible predictive factors influencing the therapeutic response to diuretics. The renal arterial resistive index (RI) (reflecting renal vascular resistance) was estimated with duplex Doppler ultrasonography.

RESULTS

Sixteen of the 27 patients (59%) responded to spironolactone alone, whereas 6 patients (22%) responded to combined diuretic therapy with spironolactone and furosemide. Five patients (19%) did not respond to diuretic treatment. Eight of the 30 variables analyzed were statistically significant as possible predictive factors influencing the diuretic response: previous episodes of ascites and gastrointestinal hemorrhage, the presence of peripheral edema, the amount of ascites, plasma renin activity, plasma aldosterone concentrations, urinary sodium excretion, and renal interlobar arterial RI. In all patients who had diuretic-resistant ascites, renal interlobar arterial RI was greater than 0.70. Only 9% of patients who responded satisfactorily to diuretic therapy had interlobar arterial RI greater than 0.70.

CONCLUSIONS

According to our results, consideration for combining the clinical findings with noninvasively measured renal arterial RI using duplex Doppler ultrasonography would be mandatory in identifying a subgroup of cirrhotic patients with ascites who are at high risk for diuretic unresponsiveness.