Treatments/Prophylaxis for Ascites and SBP

Treatment for grade 1 ascites?

No treatment

Treatment for grade 2 ascites?

Sodium restriction (<2000 mg/day) + aldosterone antagonist

• Add furosemide (or other loop diuretic) if needed for alternative treatment or a second episode

Treatment for grade 3 ascites?

LVP (+ albumin if LVP removed >5L of ascitic fluid)

+

Sodium restriction (<2000 mg/day) + aldosterone antagonist + furosemide (or other loop diuretic)

Starting dose of furosemide for ascites treatment?

40mg

Starting dose of spironolactone for ascites treatment?

100mg

40:100 furosemide:spironolactone ratio should be targeted and maintained as long as…

Patient is eukalemic:

• If excess K+, increase furosemide

• If too little K+, increase spironolactone

SAAG formula?

SAAG = serum albumin - ascitic albumin

Only use diuretics if…

SAAG ≥1.1 g/dL

Maximum volume loss allowable secondary to diuretics

500 mL or 0.5 kg/day

Indications for LVP with ascites

Grade 3 ascites that is either…

• Refractory to diuretics

• Tense, painful

• Causes shortness of breath

Contraindications to LVP:

• SBP

• Hemodynamic instability

• Thrombocytopenia (platelets <50k)

Albumin should be given after LVP if…

LVP removed >5L of ascitic fluid

Albumin dosing after LVP?

6-8 g/L of ascitic fluid removed

Indications for SBP empiric antibiotic therapy

• Patients with ascitic fluid PMN >250 cells/mm3 in a setting consistent with ascitic fluid infection,

• OR

• Patients with PMN <250 cells/mm3 but have s/s of SBP (e.g. fever, abdominal pain/tenderness)

Antibiotic agents and durations for treatment of SBP?

Ceftriaxone 2g IV daily, x 5 days

OR

Cefotaxime (2g IV q12 hours), x 5 days

Indications for primary prevention of SBP?

Patient should have the first two criteria and one criteria from the third section

• Cirrhosis + ascites

• Ascitic fluid protein <1.5 g/dL

• SCr ≥1.2, BUN ≥25, serum Na ≤130, or (Child-Pugh score ≥9 AND Tbili ≥30)

Antibiotics for primary prevention of SBP?

Ciprofloxacin 500mg PO daily, indefinitely

OR

TMP/SMX DS PO daily, indefinitely

Antibiotics for secondary prevention of SBP?

Ciprofloxacin 500mg PO daily, indefinitely

OR

TMP/SMX DS PO daily, indefinitely

—> same as abx for primary prevention of SBP

Albumin dosing as adjunctive SBP treatment?

1.5 g/kg IV on day 1, then 1g/kg on day 3