Are there special considerations when treating patients with decompensated cirrhosis?
The initial diuretic regimen for a patient with cirrhosis and ascites typically consists of oral spironolactone 100 mg daily and oral furosemide 40 mg daily. The doses may be increased if necessary, maintaining the ratio of spironolactone to furosemide at 100 mg to 40 mg. In cirrhotic patients with generalized edema, diuresis can be rather rapid. In these patients, interstitial fluid can be mobilized rapidly through capillary beds, thereby maintaining vascular volume. In patients with ascites but without peripheral edema, one must be more cautious. In these patients, ascitic fluid can be mobilized only via the peritoneal capillaries. The maximum rate at which such mobilization can occur is approximately 500 mL/day. If negative fluid balance exceeds 500 mL/day, vascular volume may fall, leading to azotemia or even hepatorenal syndrome. If more rapid fluid removal is desired in a patient with ascites but without peripheral edema, large-volume paracentesis should be considered. Care must also be taken to avoid diuretic-induced hypokalemia in cirrhotic patients. Hypokalemia leads to exchange of potassium and hydrogen ions across cell membranes. Potassium moves out of cells, and protons move into cells. The resultant intracellular acidosis stimulates ammonia synthesis in the proximal tubular cells. Hyperammonemia may induce or exacerbate hepatic encephalopathy.
