QJM Advance Access originally published online on January 9, 2008
QJM 2008 101(2):71-85; doi:10.1093/qjmed/hcm121
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Fluid retention in cirrhosis: pathophysiology and management
From the Department of Internal Medicine, Division of Gastronterology and Hepatology, University of California, Davis Medical Center, 4150 V Street - PSSB 3500, Sacramento, CA, 95817, USA
Address correspondence to Professor L. Rossaro, Department of Internal Medicine, Division of Gastronterology and Hepatology, University of California, Davis Medical Center, 4150 V Street - PSSB 3500, Sacramento, CA, 95817, USA. email: lrossaro{at}ucdavis.edu
Received 22 January 2007 and in revised form 15 November 2007
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Abstract |
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Accumulation of fluid as ascites is the most common complication of cirrhosis. This is occurring in about 50% of patients within 10 years of the diagnosis of cirrhosis. It is a prognostic sign with 1-year and 5-year survival of 85% and 56%, respectively. The most acceptable theory for ascites formation is peripheral arterial vasodilation leading to underfilling of circulatory volume. This triggers the baroreceptor-mediated activation of renin-angiotensin-aldosterone system, sympathetic nervous system and nonosmotic release of vasopressin to restore circulatory integrity. The result is an avid sodium and water retention, identified as a preascitic state. This condition will evolve in overt fluid retention and ascites, as the liver disease progresses. Once ascites is present, most therapeutic modalities are directed on maintaining negative sodium balance, including salt restriction, bed rest and diuretics. Paracentesis and albumin infusion is applied to tense ascites. Transjugular intrahepatic portosystemic shunt is considered for refractory ascites. With worsening of liver disease, fluid retention is associated with other complications; such as spontaneous bacterial peritonitis. This is a primary infection of ascitic fluid caused by organisms originating from large intestinal normal flora. Diagnostic paracentesis and antibiotic therapy plus prophylactic regimen are mandatory. Hepatorenal syndrome is a state of functional renal failure in the setting of low cardiac output and impaired renal perfusion. Its management is based on drugs that restore normal renal blood flow through peripheral arterial and splanchnic vasoconstriction, renal vasodilation and/or plasma volume expansion. However, the definitive treatment is liver transplantation.