Updated Management of Cirrhotic Ascites There are important updates in the management of cirrhotic ascites from recent AASLD, EASL, and Baveno VII guidelines (2021–2024).

1. Sodium Restriction Target: ≤2 g/day (≤90 mmol/day)Avoid overly strict restriction (<1 g/day) — worsens nutrition & outcomes. High-protein diet encouraged; malnutrition accelerates decompensation.
2. Diuretics (Dosing Updates) First-line: Spironolactone + Furosemide in 100:40 mg ratio Titrate weekly up to:Spironolactone 400 mg/dayFurosemide 160 mg/day Updates :Spironolactone still preferred over eplerenone (weak evidence for eplerenone). Avoid ACEi, ARB, NSAIDs – worsens renal perfusion. Monitor Na, K, creatinine every 3–7 days.
3. Large-Volume Paracentesis (LVP) Updated RecommendationsPerform when tense ascites regardless of diuretic status. Albumin still required:6–8 g per liter of ascites removed (20–25% albumin). New Insights Repeat paracentesis is safe and does not worsen survival.Early LVP prevents hyponatremia & renal dysfunction.
4. Albumin Infusion – Long-Term Therapy (Updated Evidence) Recent trials (ANSWER trial, 2021+) show: Long-term albumin (if available) reduces:HospitalizationRenal dysfunctionSBPDeath Regimen: 40 g twice weekly × 2 weeks, then40 g weekly maintenance Indicated in:Recurrent ascitesNa <130Impaired renal perfusionNot for patients with severe cardiac disease
5. Midodrine (Update) Now recommended for patients with hypotension + refractory ascites. Typical: 7.5–12.5 mg TIDImproves: MAPUrine sodiumResponse to diuretics
6. Refractory Ascites Management (Updated) Stepwise updated approach
7. Stop diuretics if creatinine ↑ >2 mg/dL, Na <120, severe encephalopathy.
8. Large-volume paracentesis + albumin.3. Add Midodrine ± Octreotide (newer supportive evidence).
9. TIPS earlier than previously recommended (see below).
10. TIPS – Important Updates Strong update from Baveno VIIEarly TIPS is now recommended for:Recurrent or refractory ascitesAbsence of severe HEMELD ≤18–20 Benefits of Early TIPS: Improved survivalBetter quality of lifeReduced paracentesis need Contraindications remain: Severe pulmonary hypertensionCHF, LVEF <50%Uncontrolled hepatic encephalopathySevere liver failure (MELD >25)
11. Vasoconstrictor + Albumin Combo (Newer Data) For refractory ascites with low MAP: Midodrine + Octreotide + AlbuminShows improved natriuresis and decreased ascites recurrence.
12. SGLT-2 Inhibitors (Emerging evidence – not standard yet) Small studies note: ↓ Ascites accumulation↑ Urine sodium Improved diabetes and renal parametersNot yet guideline-approved but promising.
13. Avoidance Strategies (Updated) Avoid NS in hospital (worsens ascites).Avoid ACEi/ARB, NSAIDs, SGLT2 in advanced AKI, aggressive furosemide boluses.Avoid fluid restriction unless Na <120.
14. SBP Prophylaxis (Updated)Indications include: Low-protein ascitic fluid (<1.5 g/dL) plus renal dysfunction or liver failure. Prior SBP. Regimen:Norfloxacin 400 mg daily orTMP-SMX DS 5×/week(Note: Norfloxacin availability varies by region.)
15. Liver Transplant Referral Update:Any patient requiring repeated paracentesis or refractory ascites should be referred early. Ascites is an indicator of 50% 1-year mortality if untreated.