Abstract
The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to summarize the available evidence and offer expert Best Practice Advice (BPA) on the management of ascites, hepatic hydrothorax, volume overload, and hyponatremia in patients with cirrhosis.
This expert review was commissioned and approved by the AGA Institute Governing Board and Clinical Practice Updates Committee (CPUC) to provide timely guidance on a topic of high clinical importance to the AGA membership. This CPU expert review underwent internal peer review by the CPUC and external peer review through the standard procedures of Gastroenterology. These BPA statements were developed based on review of the published literature and expert opinion and approved by the AGA Institute Governing Board. Because formal systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: Patients with cirrhosis with ascites, hepatic hydrothorax, or volume overload should be managed with dietary sodium restriction and diuretics at the lowest effective dose, with dose escalation guided by symptoms, weight, urine output, and electrolyte/renal monitoring. Education and referral to a dietitian should be provided for dietary management. Triggers of liver decompensation should be identified and addressed. BEST PRACTICE ADVICE 2: Patients with cirrhosis with new-onset ascites, or those admitted to the hospital for symptoms related to ascites or encephalopathy should receive diagnostic paracentesis as soon as possible. Testing should include serum ascites albumin gradient and cell count, Gram stain, and culture. BEST PRACTICE ADVICE 3: Patients with hepatic hydrothorax with dyspnea and/or hypoxemia should undergo a therapeutic thoracentesis for both symptom relief and expansion of the underlying lung. BEST PRACTICE ADVICE 4: All patients with refractory ascites and/or hepatic hydrothorax should be considered for liver transplantation evaluation, regardless of their Model for End-Stage Liver Disease score. BEST PRACTICE ADVICE 5: Refractory ascites and/or hydrothorax should be managed with therapeutic paracentesis and/or thoracentesis, respectively, with the frequency guided by recurrence. BEST PRACTICE ADVICE 6: When the volume of ascites removed is >5 L, 20%-25% intravenous albumin 6-8 g per every total liter removed should be administered. For patients with hypotension, renal insufficiency, or electrolyte abnormalities, albumin should also be considered for removal of smaller volumes. BEST PRACTICE ADVICE 7: Well-selected patients with refractory ascites, hepatic hydrothorax, volume overload, or hyponatremia should be referred for to transjugular intrahepatic portosystemic shunt. BEST PRACTICE ADVICE 8: Diagnostic workup for the etiology of hyponatremia in cirrhosis should include dietary and medication history (diuretics, bowel regimen); review of electrolyte and kidney function; gastrointestinal bleeding assessment; infectious workup, including diagnostic paracentesis, and evaluation of secondary causes (thyroid or adrenal dysfunction). BEST PRACTICE ADVICE 9: Outpatient management of asymptomatic hypervolemic hyponatremia in liver cirrhosis entails both sodium and water restriction (aiming for 1-1.5 L of daily fluid intake), modification of diuretics and laxatives, and monitoring of electrolytes. BEST PRACTICE ADVICE 10: Inpatient management of severe or symptomatic hypervolemic hyponatremia in liver cirrhosis includes both sodium and water restriction; modification or discontinuation of diuretics and laxatives; and additional measures, such as intravenous albumin based on volume assessment or oral vasoconstriction therapy. BEST PRACTICE ADVICE 11: Recurrent or refractory hyponatremia management should involve a multidisciplinary approach (including the liver transplantation team when appropriate) and can consider several therapeutic options, including intravenous vasoconstrictor therapy, infusion of hypertonic saline, use of vasopressin receptor antagonist (vaptans), or use of renal replacement therapy. BEST PRACTICE ADVICE 12: Inpatient management of volume overload includes escalation or trial of intravenous loop diuretics (furosemide or bumetanide) in bolus (2-3 times per day) or continuous fashion. Cautious escalation can be done every 2-3 days with monitoring of volume status, kidney function, daily weights, and symptoms. BEST PRACTICE ADVICE 13: Advanced strategies in refractory anasarca should be coordinated with nephrology for consideration of diuretics in the setting of contraction alkalosis (eg, addition of acetazolamide), second agent with alternate mechanism of actions (eg, thiazide diuretics, such as metolazone), or need for ultrafiltration.