Ascites due to cirrhosis can be mobilized in approximately 90 percent of patients with a treatment regimen consisting of dietary sodium restriction (usually 88 mEq [2000 mg] per day) and oral diuretics (usually consisting of spironolactone and furosemide) . (See "Ascites in adults with cirrhosis: Initial therapy".)
Patients with diuretic-resistant ascites have pre-hepatorenal syndrome and a poor prognosis . The two-year survival rate of all patients with cirrhosis after the development of ascites is approximately 50 percent [3,4]. By comparison, survival in patients with diuretic-resistant ascites is 50 percent at six months and 25 percent at one year .
This topic will review the approach to the 10 percent of patients who appear to have diuretic-resistant ascites (also referred to as refractory ascites). The diagnosis and evaluation of patients with ascites, the initial therapy of ascites due to cirrhosis, and the management of spontaneous bacterial peritonitis are discussed elsewhere. (See "Evaluation of adults with ascites" and "Ascites in adults with cirrhosis: Initial therapy" and "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis".)
The management of ascites in adults with cirrhosis is also discussed in a 2013 guideline from the American Association for the Study of Liver Diseases (table 1) [6,7]. The discussion that follows is consistent with that guideline.
True diuretic-resistant ascites is usually associated with advanced cirrhosis, marked neurohumoral activation (of the sympathetic and renin-angiotensin-aldosterone systems), and very low urinary excretion of sodium, frequently less than 10 mEq/day despite maximal tolerated doses of diuretics [1,2].