Management Ascites		Ascites in patients with cholestasis is a harbinger of end-stage liver disease. Its causes are many, including portal hypertension, hypoalbuminemia and sodium retention. Almost 50% of patients will die within 2 years of developing ascites. Ascites is initially treated by a combination of a low-sodium diet (1-2 meq/kg/day) and spironolactone, an aldosterone-antagonist diuretic. A starting dose of 3-5 mg/kg/day in 3-4 divided doses can be increased up to 10-12 mg/kg/day as necessary. Because of the central role of sodium retention in the pathogenesis of ascites, the goal is a urine sodium > 15 meq/kg/day. To achieve this, it may be necessary to add Lasix and even fluid restriction to 50-75% of maintenance. Net water loss of 200-300 cc/day is desirable, however overaggressive treatment can lead to hypovolemia and acute renal failure. In refractory cases, especially those with hypoalbuminemia, IV albumin (0.5-1 gm/kg/dose) followed by IV Lasix (1 mg/kg/dose) 2-3 times/day can be helpful. Persistent ascites, especially if it causes respiratory compromise, is treated with therapeutic paracentesis. Last resort treatments are portosystemic shunts to decrease the portal hypertension and liver transplant. Return to top of page