REFRACTORY ASCITES

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REFRACTORY ASCITES
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DEFINITIONS

• Refractory ascites Is the ascites that cannot be
  mobilized or the early recurrence of which
  cannot be satisfactorily prevented by medical
  therapy.

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• The term refractory ascites includes the
  following two subtypes.
• Diuretic-resistant ascites is refractory ascites
  due to a lack of response to dietary sodium
  restriction and intensive diuretic therapy.
• Diuretic-intractable ascites is refractory
  ascites due to the development of
  diuretic-induced complications that preclude the
  use of an effective diuretic dosage.

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PREVALENCE

• The prevalence of ascites refractory to medical
  therapy is 5 to 10 .

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PATHOGENESIS

• The pathophysiologic factors leading to
  refractory ascites are an exaggeration of the
  factors primarily responsible for sodium and
  water retention in liver cirrhosis

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Cont. pathogenesis

• Being characterized by
• Severely decreased systemic vascular resistance
• A hyperdynamic circulation, with an increased
  cardiac output, a low arterial pressure, and a
  high pulse rate
• Greatest activation of the sympathetic nervous
  system and renin-angiotensin-aldosterone system
  and non osmotic release of ADH
• Considerable reduction of the renal blood flow
  (RBF) and the glomerular filtration rate (GFR) in
  patients with decreased central blood volume

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PROGNOSIS

• Generally, the survival rate of patients with
  ascites is approximately 50 at 2 years, whereas
  the survival rate in cases of refractory ascites
  is reduced to 50 at 6 months .

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DIAGNOSTIC CRITERIA

• Treatment duration Patients must be on intensive
  diuretic treatment for at least 1 week.
• Lack of response Mean loss of weight less than
  200g/day during the last 4 days of intensive
  diuretic therapy and urinary sodium excretion
  lower than 50mEq/day.
• Dietary sodium restriction A 50-mEq sodium diet.
• Intensive diuretic treatment Spironolactone
  400mg/day plus furosemide 160mg/day (bumetanide
  4mg/day or equivalent doses of loop diuretics).

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Cont. diagnostic criteria

• Early ascites recurrence Reappearance of grade 2
  (moderate) to 3 (massive or tense) ascites within
  4 weeks of initial mobilization.
• Diuretic induced complications
• Hepatic encephalopathy
• In the absence of other precipitating factors.

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Cont. diagnostic criteria

• Renal failure
• Increased serum creatinine to a value of 2
  gm/dl in patients with ascites responding to
  diuretics.
• Hyponatremia
• Decreased serum sodium to a value lower than 125
  mEq/L.
• Hypo or hyperkalemia
• Decreased serum potassium to a value lower than 3
  mEq /L or an increase to a value greater than 6
  mEq /L .