Refractory ascites—the contemporary view on pathogenesis and therapy

Abstract

Refractory ascites (RA) refers to ascites that cannot be mobilized or that has an early recurrence that cannot be prevented by medical therapy. Every year, 5–10% of patients with liver cirrhosis and with an accumulation of fluid in the peritoneal cavity develop RA while undergoing standard treatment (low sodium diet and diuretic dose up to 400 mg/day of spironolactone and 160 mg/day of furosemide). Liver cirrhosis accounts for marked alterations in the splanchnic and systemic hemodynamics, causing hypovolemia and arterial hypotension. The consequent activation of renin-angiotensin and sympathetic systems and increased renal sodium re-absorption occurs during the course of the disease. Cirrhotic patients with RA have poor prognoses and are at risk of developing serious complications. Different treatment options are available, but only liver transplantation may improve the survival of such patients.

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan

“…Ascites that cannot be mobilized or the early recurrence of which (i.e., after LVP) cannot be satisfactorily prevented by medical therapy. 4 , 47 …”

“…Ascites: Ascites that cannot be mobilized or the early recurrence of which (i.e., after LVP) cannot be satisfactorily prevented by medical therapy. 4,47 Refractory ascites has two subtypes: Diuretic-resistant ascites: Ascites that cannot be mobilized or the early recurrence of which cannot be prevented because of a lack of response to sodium restriction and permissible dose of diuretics Diuretic-intractable ascites: Ascites that cannot be mobilized or the early recurrence of which cannot be prevented because of the development of diuretic induced complications that preclude the use of an effective diuretic dosage Requisites for a diagnosis of refractory ascites: 10, 14 1. Treatment duration: Patients must be on maximum permissible dose of diuretics i.e.…”

“…7 Patients requiring paracenteses of approximately 10 L or more, less than two weeks interval, are likely not following a salt restricted diet. 47 Repeated therapeutic paracentesis should be reserved for those 10% patients who are proven to be diuretic refractory. Midodrine is as effective as albumin in reducing morbidity and mortality among patients with refractory ascites undergoing LVP at a significantly lower cost.…”

The Incidence of Spontaneous Bacterial Peritonitis in Patients With Cirrhosis-Related Ascites Undergoing Elective Outpatient Large-Volume Paracentesis

“…"Refractory ascites" describes ascites that cannot be controlled and managed by diet and the use of diuretics; it requires regular large-volume paracentesis (LVP) or the creation of trans-jugular intrahepatic portosystemic shunts (TIPSS) [9]. In asymptomatic outpatients presenting for elective LVP, the incidence of SBP is reported to be less than that in symptomatic patients; this lower incidence is also associated with lower morbidity and mortality [5].…”