Current treatment strategies: diuretics

Diuretics are needed to counteract renal sodium retention in decompensated cirrhosis, which is responsible for ascites and edema formation. As secondary hyperaldosteronism is a major pathogenetic mechanism, aldosterone antagonists should be always administered, up to 400 mg/day. They have a very long elimination half-life and can be given once daily. Their main side effects are hyperkalemia and painful gynecomastia. When glomerular filtration rate declines, as occurs in the advanced stages of the disease, excessive sodium reabsorption by the proximal tubule becomes the main cause of sodium retention. In such cases, loop diuretics should be associated. These very potent and short-acting drugs should be given with caution because of their potential side-effects: renal impairment, hyponatremia, hypokalemia, hypochloremic alkalosis and hepatic encephalopathy. The maximum recommended dosage for furosemide is 160 mg/day, which is seldom reached in clinical practice because of adverse side effects at lower doses. Treatment can be sequential, that is starting with aldosterone antagonist monotherapy at increasing doses, with the eventual addition of a loop diuretic in case of failure, or combined, that is starting with the association straight away. Controlled clinical trials suggest that sequential treatment is to be preferred in patients with ascites at the first appearance and well preserved glomerular filtration rate, where natriuresis can be achieved in more than 90% of cases and dose adjustments are less common. Patients with long-standing recidivant ascites would benefit from the combined treatment, which induces natriuresis more rapidly with a lower incidence of hyperkalemia.