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Chronic Liver Failure pp 411–427Cite as

Management of Ascites and Hyponatremia

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Abstract

Patients with cirrhosis frequently develop disturbances in body fluid regulation that result in an increase in the volume of extracellular fluid which accumulates as ascites and/or edema (1).

Grant support: Some of the studies reported in this chapter have been performed with the support of grants from the Fondo de Investigación Sanitaria, Ministerio de Ciencia e Innovación: Fondo de Instituto de Salud Carlos III, FIS08; PI080126, EC07/90077

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Notes

  1. 1.

    Grant support: Some of the studies reported in this chapter have been performed with the support of grants from the Fondo de Investigación Sanitaria, Ministerio de Ciencia e Innovación: Fondo de Instituto de Salud Carlos III, FIS08; PI080126, EC07/90077

References

  1. Arroyo V, Ginès P, Planas R, Rodés J. Pathogenesis, diagnosis and treatment of ascites in cirrhosis. In: McIntyre N, Benhamou JP, Bircher J, Rizetto M, Rodés J, eds. Oxford Textbook of Clinical Hepatology. 2nd ed. Humana Press, 1999; 697–732.

    Google Scholar 

  2. Cárdenas A, Ginès P. Mechanisms of ascites formation. In: Sanyal A, Shah V, eds. Portal Hypertension. Totowa, NJ: Humana Press, 2005; 65–84.

    Chapter  Google Scholar 

  3. Ginès P, Cárdenas A, Schrier R. Liver disease and the kidney. In: Schrier R, ed. Diseases of the Kidney and Urinary Tract. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007; 2179–205.

    Google Scholar 

  4. Angeli P, Gatta A. Medical treatment of ascites in cirrhosis. In: Ginès P, Arroyo V, Rodes J, Schrier R, eds. Ascites and Renal Dysfunction in Liver Disease. 2nd ed.Oxford: Blackwell Publishing, 2005; 227–40.

    Chapter  Google Scholar 

  5. Bernardi M, Laffi G, Salvagnini M, et al. Efficacy and safety of the stepped care medical treatment of ascites in liver cirrhosis: a randomized controlled clinical trial comparing two diets with different sodium content. Liver 1993;13:156–62.

    CAS  PubMed  Google Scholar 

  6. Pérez-Ayuso RM, Arroyo V, Planas R, et al. Randomized comparative study of efficacy of furosemide versus spironolactone in nonazotemic cirrhosis with ascites. Relationship between the diuretic response and the activity of the renin–aldosterone system. Gastroenterology 1983;84:961–8.

    PubMed  Google Scholar 

  7. Angeli P, Pria MD, De Bei E, et al. Randomized clinical study of the efficacy of amiloride and potassium canreonate in nonazotemic cirrhotic patients with ascites. Hepatology 1994;19:72–9.

    Article  CAS  PubMed  Google Scholar 

  8. Strauss E, De SaMF, Lacet CM, et al. Standardization of a therapeutic approach for ascites due to chronic liver disease. A prospective study of 100 patients. Gastrointest Endosc Digest 1985;4:79–86.

    Google Scholar 

  9. Gatta A, Angeli P, Caregaro L, et al. A pathophysiological interpretation of unresponsiveness to spironolactone in a stepped-care approach to the diuretic treatment of ascites in nonazotemic cirrhotic patients. Hepatology 1991;14:231–6.

    Article  CAS  PubMed  Google Scholar 

  10. Arroyo V, Ginès P, Gerbes A, et al. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. Hepatology 1996;23:164–7.

    Article  CAS  PubMed  Google Scholar 

  11. Santos J, Planas R, Pardo A, et al. Spironolactone alone or in combination with furosemide in the treatment of moderate ascites in nonazotemic cirrhosis. A randomized comparative study of efficacy and safety. J Hepatol 2003;39:187–92.

    Article  CAS  PubMed  Google Scholar 

  12. Angeli P, Fasolato S, Mazza E, et al. Combined versus sequential diuretic treatment of ascites in nonazotemic patients with cirrhosis: results of an open randomized clinical trial. Gut 2010;59:98–104.

    Article  CAS  PubMed  Google Scholar 

  13. Gregory PB, Broekelschen PH, Hill MD, et al. Complications of diuresis in the alcoholic patient with ascites: a controlled trial. Gastroenterology 1977;73:534–8.

    CAS  PubMed  Google Scholar 

  14. Mimidis K, Papadopoulos V, Kartalis G. Eplerenone relieves spironolactone-induced painful gynaecomastia in patients with decompensated hepatitis B-related cirrhosis. Scand J Gastroenterol 2007;42:1516–7.

    Article  CAS  PubMed  Google Scholar 

  15. Angeli P, Albino G, Carraro P, et al. Cirrhosis and muscle cramps: evidence of a causal relationship. Hepatology 1996;23:264–73.

    Article  CAS  PubMed  Google Scholar 

  16. Ginès P, Arroyo V, Quintero E, et al. Comparison of paracentesis and diuretics in the treatment of cirrhotics with tense ascites. Results of a randomized study. Gastroenterology 1987;93:234–41.

    PubMed  Google Scholar 

  17. Salerno F, Badalamenti S, Incerti P, et al. Repeated paracentesis and iv albumin infusion to treat “tense” ascites in cirrhotic patients: a safe alternative therapy. J Hepatol 1987;5:102–8.

    Article  CAS  PubMed  Google Scholar 

  18. Acharya SK, Balwinder S, Padhee AK, et al. Large-volume paracentesis and intravenous dextran to treat tense ascites. J Clin Gastroenterol 1992;14:31–5.

    Article  CAS  PubMed  Google Scholar 

  19. Solà R, Vila MC, Andreu M, et al. Total paracentesis with dextran 40 vs. diuretics in the treatment of ascites in cirrhosis: a randomized controlled study. J Hepatol 1994;20:282–8.

    Article  PubMed  Google Scholar 

  20. Fernández-Esparrach G, Guevara M, Sort P, et al. Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double-blind trial of spironolactone versus placebo. J Hepatol 1997;26:614–20.

    Article  PubMed  Google Scholar 

  21. Moore KP, Wong F, Ginès P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology 2003;38:258–66.

    Article  PubMed  Google Scholar 

  22. Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006;55(Suppl 6):vi1–12.

    Article  PubMed  Google Scholar 

  23. Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009;49:2087–107.

    Article  PubMed  Google Scholar 

  24. Garcia-Tsao G, Lim JK, Members of Veterans Affairs Hepatitis C Resource Center Program. 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. Am J Gastroenterol 2009;104:1802–29.

    Article  PubMed  Google Scholar 

  25. European Association for the Study of the Liver, Ginès P, Angeli P, Lenz K, et al. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53(3):397–417.

    Google Scholar 

  26. Ginès P, Titó Ll, Arroyo V, et al. Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis. Gastroenterology 1988;94:1493–502.

    PubMed  Google Scholar 

  27. Ruiz del Arbol L, Monescillo A, Jiménez W, et al. Paracentesis-induced circulatory dysfunction: mechanism and effect on hepatic hemodynamics in cirrhosis. Gastroenterology 1997;113:579–86.

    Article  Google Scholar 

  28. Ginès A, Fernández-Esparrach G, Monescillo A, et al. Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology 1996;111:1002–10.

    Article  PubMed  Google Scholar 

  29. Sola-Vera J, Miñana J, Ricart E, et al. Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology 2003;37:1147–53.

    Article  CAS  PubMed  Google Scholar 

  30. Ferral H, Bjarnason H, Wegryn SA, et al. Refractory ascites: early experience in treatment with transjugular intrahepatic portosystemic shunt. Radiology 1993;189:7905–801.

    Google Scholar 

  31. Somberg KA, Lake JR, Tomlanovich SJ, et al. Transjugular intrahepatic portosystemic shunt for refractory ascites: assessment of clinical and humoral response and renal function. Hepatology 1995;21:709–16.

    CAS  PubMed  Google Scholar 

  32. Ochs A, Rossle M, Haag K, et al. The transjugular intrahepatic portosystemic stent shunt procedure for refractory ascites. N Engl J Med 1995;332:1192–7.

    Article  CAS  PubMed  Google Scholar 

  33. Wong F, Sniderman K, Liu P, et al. Transjugular intrahepatic portosystemic stent shunt: effects on hemodynamics and sodium homeostasis in cirrhosis and refractory ascites. Ann Intern Med 1995;122:816–22.

    CAS  PubMed  Google Scholar 

  34. Casado M, Bosch J, Garcia-Pagan JC, et al. Clinical events after transjugular, intrahepatic portosystemic shunt: correlation with hemodynamic findings. Gastroenterology 1998;114:1296–303.

    Article  CAS  PubMed  Google Scholar 

  35. Boyer TD. Transjugular intrahepatic portosystemic shunt in the management of complications of portal hypertension. Curr Gastroenterol Rep 2008;10:30–5.

    Article  PubMed  Google Scholar 

  36. Jung HS, Kalva SP, Greenfield AJ, Waltman AC, Walker TG, Athanasoulis CA, Wicky ST. TIPS: comparison of shunt patency and clinical outcomes between bare stents and expanded polytetrafluoroethylene stent-grafts. J Vasc Interv Radiol 2009;20:180–5.

    Article  PubMed  Google Scholar 

  37. Lebrec D, Giuily N, Hadengue A, et al. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. J Hepatol 1996;25:135–44.

    Article  CAS  PubMed  Google Scholar 

  38. Rossle M, Ochs A, Gulberg V, et al. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Engl J Med 2000;342:1701–7.

    Article  CAS  PubMed  Google Scholar 

  39. Ginès P, Uriz J, Calahorra B, et al. Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002;123:1839–47.

    Article  PubMed  Google Scholar 

  40. Sanyal A, Genning C, Reddy RK, et al. The North American study for the treatment of refractory ascites. Gastroenterology 2003;124:634–41.

    Article  PubMed  Google Scholar 

  41. Salerno F, Merli M, Riggio O, et al. Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites. Hepatology 2004;40:629–35.

    Article  CAS  PubMed  Google Scholar 

  42. Saab S, Nieto JM, Lewis SK, Runyon BA. TIPS versus paracentesis for cirrhotic patients with refractory ascites. Cochrane Database Syst Rev 2006 Oct 18;(4):CD004889.

    Google Scholar 

  43. Albillos A, Banares R, Gonzales M, et al. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol 2005;43:990–6.

    Article  PubMed  Google Scholar 

  44. Dámico G, Luca A, Morabito A, et al. Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis. Gastroenterology 2005;129:1282–93.

    Article  Google Scholar 

  45. Salerno F, Camma C, Enea M, et al. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology 2007;133:825–34.

    Article  CAS  PubMed  Google Scholar 

  46. Ginès P, Guevara M. Hyponatremia in cirrhosis: pathogenesis, clinical significance and management. Hepatology 2008;48:1002–10.

    Article  PubMed  Google Scholar 

  47. Arroyo V, Rodés J, Gutiérrez-Lizárraga MA, Revert L. Prognostic value of spontaneous hyponatremia in cirrhosis with ascites. Am J Dig Dis 1976;21:249–56.

    Article  CAS  PubMed  Google Scholar 

  48. Biggins S, Rodriguez HJ, Bachetti P, Bass NM, Robert JP, Terrault NA. Serum sodium predicts mortality in patients listed for liver transplantation. Hepatology 2005;41:32–9.

    Article  CAS  PubMed  Google Scholar 

  49. Ruf AE, Kremers WK, Chavez LL, Descalzi VI, Podesta LG, Villamil FG. Addition of serum sodium into the MELD score predicts waiting list mortality better than MELD alone. Liver Transpl 2005;11:336–43.

    Article  PubMed  Google Scholar 

  50. Biggins SW, Kim WR, Terrault NA, et al. Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 2006;130:1652–60.

    Article  PubMed  Google Scholar 

  51. Londoño MC, Cardenas A, Guevara M, et al. MELD score and serum sodium in the prediction of survival of patients with cirrhosis awaiting liver transplantation. Gut 2007;56:1283–90.

    Article  PubMed  Google Scholar 

  52. Londoño MC, Guevara M, Rimola A, et al. Hyponatremia impairs early posttransplantation outcome in patients with cirrhosis undergoing liver transplantation. Gastroenterology 2006;130:1135–43.

    Article  PubMed  Google Scholar 

  53. Jalan R, Elton RA, Redhead DN, Simpson KJ, Finlayson NDC, Hayes PC, et al. Analysis of prognostic variables in the prediction of shunt failure, variceal rebleeding, early mortality and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt (TIPSS). J Hepatol 1995;23:123–8.

    Article  CAS  PubMed  Google Scholar 

  54. Guevara M, Baccaro ME, Torre A, Gómez-Anson B, Rios J, Torres F, et al. Hyponatremia is a risk factor of hepatic encephalopathy in patients with cirrhosis. A prospective study with time-dependent analysis. Am J Gastroenterol 2009;104:1382–9.

    Article  PubMed  Google Scholar 

  55. Jalan R, Mookerjee R, Cheshire L, Williams R, et al. Albumin infusion for severe hyponatremia in patients with refractory ascites: a randomized clinical trail. J Hepatol 2007;46:232A.

    Article  Google Scholar 

  56. McCormick PA, Mistry P, Kaye G, Burroughs AK, McIntyre N. Intravenous albumin infusion is an effective therapy for hyponatraemia in cirrhotic patients with ascites. Gut 1990;31:204–7.

    Article  CAS  PubMed  Google Scholar 

  57. Decaux G, Soupart A, Vassart G. Non-peptide arginine–vasopressin antagonists: the vaptans. Lancet 2008;371:1624–32.

    Article  CAS  PubMed  Google Scholar 

  58. Wong F, Blei AT, Blendis LM, Thuluvath PJ. A vasopressin receptor antagonist (VPA-985) improves serum sodium concentration in patients with hyponatremia: a multicenter, randomized, placebo-controlled trial. Hepatology 2003;37:182–91.

    Article  CAS  PubMed  Google Scholar 

  59. Gerbes AL, Gulberg V, Ginès P, et al. VPA Study Group. Therapy of hyponatremia in cirrhosis with a vasopressin receptor antagonist: a randomized double-blind multicenter trial. Gastroenterology 2003;124:933–9.

    Article  CAS  PubMed  Google Scholar 

  60. Schrier RW, Gross P, Gheorghiade M, et al. Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med 2006;355:2099–112.

    Article  CAS  PubMed  Google Scholar 

  61. Ginès P, Wong F, Watson H, et al. Effects of satavaptan, a selective vasopressin V(2) receptor antagonist, on ascites and serum sodium in cirrhosis with hyponatremia: a randomized trial. Hepatology 2008;48:204–13.

    Article  PubMed  Google Scholar 

  62. O’Leary JG, Davis GL. Conivaptan increases serum sodium in hyponatremic patients with end-stage liver disease. Liver Transpl 2009;15:1325–9.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Gastrointestinal Unit, Hospital Clínic and University of Barcelona School of Medicine, Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepaticas y Digestivas (CIBERHED), Barcelona, Spain

    Andrés Cárdenas

  2. Liver Unit, Hospital Clínic and University of Barcelona School of Medicine, Institut d’Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Ciber de Enfermedades Hepaticas y Digestivas (CIBERHED), Barcelona, Spain

    Pere Ginès

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  1. Andrés Cárdenas
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Editors and Affiliations

  1. Liver Unit, Hospital Clinic, University of Barcelona, Villarroel 170, Barcelona, 08036, Spain

    Pere Ginès

  2. College of Medicine, Division of Gastroenterology and Hepatol, Mayo Clinic, 200 First St. S.W, Rochester, 55905, Minnesota, USA

    Patrick S. Kamath

  3. Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, 08036, Spain

    Vicente Arroyo

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Cárdenas, A., Ginès, P. (2011). Management of Ascites and Hyponatremia. In: Ginès, P., Kamath, P., Arroyo, V. (eds) Chronic Liver Failure. Clinical Gastroenterology. Humana Press. https://doi.org/10.1007/978-1-60761-866-9_21

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