AGA releases best practice advice on cirrhosis
The guidance from the American Gastroenterological Association (AGA) covered management of ascites, hepatic hydrothorax, volume overload, and hyponatremia in and out of the hospital.
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 escalation guided by symptoms, weight, urine output, and electrolyte/renal monitoring, according to new best practice advice from the American Gastroenterological Association.
The goal of the best practice advice was to provide updated guidance on management of certain conditions in patients with cirrhosis. The statements were developed based on review of the literature and expert opinion and were published by Gastroenterology on Oct. 20.
Patients with cirrhosis with ascites, hepatic hydrothorax, or volume overload should also receive education and referral to a dietitian, and triggers of liver decompensation should be identified and addressed, the guidance said. 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, according to the guidance, and testing for serum ascites albumin gradient and cell count, Gram stain, and culture should also be done.
The statement said that refractory ascites and/or hydrothorax should be managed with therapeutic paracentesis and/or thoracentesis, respectively, with the frequency guided by recurrence. When the volume of ascites removed exceeds 5 L, 20% to 25% IV albumin should be administered, 6 to 8 g per every total liter removed, the statement said. For patients with hypotension, renal insufficiency, or electrolyte abnormalities, albumin should also be considered for removal of smaller volumes, according to the statement.
To evaluate the cause of hyponatremia in patients with cirrhosis, diagnostic workup should include dietary and medication history, review of electrolyte and kidney function, a GI bleeding assessment, infectious workup (including diagnostic paracentesis), and evaluation of secondary causes, such as thyroid or adrenal dysfunction, the statement said. For outpatient management of asymptomatic hypervolemic hyponatremia in cirrhosis, both sodium and water should be restricted, with a goal of 1 to 1.5 L of fluid intake daily; use of diuretics and laxatives should be modified, and electrolytes should be monitored, according to the statement.
Inpatient management of severe or symptomatic hypervolemic hyponatremia should also include additional measures, such as IV albumin based on volume assessment or oral vasoconstriction therapy, while inpatient management of volume overload should include escalation or a trial of IV loop diuretics (furosemide or bumetanide) in bolus (two to three times daily) or continuously. Therapy can be escalated cautiously every two to three days while monitoring volume status, kidney function, daily weights, and symptoms, the statement said.
“Liver transplantation remains the only curative option for patients with cirrhosis with ascites, fluid overload, and hyponatremia,” the statement authors wrote. “However, given the significant gap between donor organ supply and transplant demand, other strategies are needed to either bridge patients to transplantation or provide improvement in quality of life for those without timely access.”