Management of Refractory Ascites

A 56-year-old man with hepatitis C–related cirrhosis is admitted for management of ascites. Despite a 90-mEq sodium–restricted diet and high doses of diuretics (spironolactone 400 mg/day and furosemide 160 mg/day), the ascites has not been well controlled for the past 4 weeks. Physical examination reveals an arterial pressure of 90/70 mm Hg, heart rate of 98 bpm, lower extremity edema, stigmata of cirrhosis with temporal wasting, mild icterus and spider angiomas, tense ascites, splenomegaly, and grade 1 encephalopathy. His hemoglobin level is 12 g/dL, white cell count is 3.8 × 10⁹/L, and platelet count is 79 × 10⁹/L. Other laboratory test results are AST, 44 U/L; ALT, 57 U/L; serum bilirubin, 3.1 mg/dL; albumin, 3.2 g/dL; international normalized ratio (INR) for prothrombin time, 1.9; serum sodium, 129 mEq/L; potassium, 5.2 mEq/L; blood urea nitrogen, 22 mg/dL; and serum creatinine, 1.7 mg/dL. A diagnostic paracentesis does not reveal evidence of spontaneous bacterial peritonitis. Ultrasound examination of the liver does not show any portal vein thrombosis or liver masses. How should this patient be managed, and what is the role of large volume paracentesis, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation in this patient?

Abbreviations used in this paper:  HRS, hepatorenal syndrome , INR, international normalized ratio , MELD, Model for End-Stage Liver Disease , TIPS, transjugular intrahepatic portosystemic shunt