A 38-year-old man with Child-Pugh B cirrhosis develops large-volume ascites. He is started on spironolactone 100 mg and furosemide 40 mg with restricted sodium intake. After 4 weeks, serum sodium is 128 mEq/L, potassium 3.2 mEq/L, and ascites persist. Which adjustment is MOST appropriate?
- A Increase spironolactone to 400 mg and furosemide to 160 mg
- B Perform large-volume paracentesis with IV albumin (6-8 g per litre removed) ✓
- C Add tolvaptan for hyponatraemia
- D Restrict water intake to 1 L/day and add 3% saline
Explanation
In cirrhotic ascites not responding to diuretics, or where diuretic escalation is limited by hyponatraemia (Na <130) and hypokalaemia, large-volume paracentesis (LVP) with albumin infusion is the recommended step. Post-paracentesis circulatory dysfunction (PPCD) is prevented by IV albumin 6-8 g per litre of ascites removed beyond 5 litres (8 g/L for complete drainage). EASL 2018 guidelines recommend LVP as first-line for tense/refractory ascites. Tolvaptan improves serum sodium but does not control ascites and carries hepatotoxicity risk in cirrhosis. Further diuretic dose escalation risks precipitating hepatic encephalopathy and AKI.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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