Managing Ascites: Navigating Kidney and Liver Issues in Advanced Disease

It is unclear whether the ascites is caused by kidney issues or liver problems. How can this be addressed?

I have hepatitis B, cirrhosis, and liver cancer.
Targeted therapy was interrupted due to side effects, and the hospital suddenly informed us that I am now in the late stage of cirrhosis, which has caused ascites and edema, as well as stage 5 renal failure.
I asked the hepatologist if it would be better to stabilize my condition with dialysis before treating my liver, and he agreed.
I then asked the nephrologist if we could proceed with dialysis, and he said I am not yet at the stage for dialysis, as I can still manage my electrolytes.
He mentioned that while dialysis is possible, the patient's condition is at risk of infection.
It seems that the two doctors have different opinions and have not communicated effectively, leaving the patient unsure of what to do.
Recently, the ascites has worsened significantly, and despite using diuretics, the condition remains severe.
Besides paracentesis, are there any other treatment options available?

inzu, 60~69 year old female. Ask Date: 2023/09/21

Dr. Yan Qitai reply Internal Medicine

Considering your condition, it is recommended to continue follow-up visits and treatment with the Gastroenterology and Hepatology Department as well as the Nephrology Department.
The physician will provide appropriate medical advice based on your condition during each visit.
Department of Nephrology, Tainan Hospital, Ministry of Health and Welfare, Dr.
Yen Chi-Tai.

Reply Date: 2023/09/21

More Info

Managing ascites in patients with advanced liver disease, particularly those with concurrent kidney issues, is a complex and multifaceted challenge. Given your mother's diagnosis of hepatitis B, cirrhosis, liver cancer, and stage five kidney failure, it is crucial to approach her treatment with a comprehensive understanding of both liver and kidney functions.

Ascites, the accumulation of fluid in the abdominal cavity, is a common complication of cirrhosis. It occurs due to increased pressure in the portal vein (portal hypertension) and decreased oncotic pressure from low albumin levels. In advanced liver disease, the liver's ability to produce proteins diminishes, leading to fluid retention and swelling. The management of ascites typically involves dietary sodium restriction, diuretics, and, in more severe cases, therapeutic paracentesis (removal of fluid via needle).

In your mother's case, the use of diuretics has not sufficiently controlled her ascites, which raises concerns about the underlying liver function and the potential for kidney involvement. The kidneys play a vital role in fluid balance, and their impairment can exacerbate fluid retention. The conflicting opinions from her liver and kidney specialists highlight the complexity of her condition. While the liver doctor suggests that stabilizing kidney function through dialysis may allow for further liver treatment, the nephrologist indicates that her current kidney function does not warrant dialysis yet.

Here are some considerations and potential management strategies for your mother's condition:
1. Regular Monitoring: Continuous monitoring of liver and kidney function is essential. Blood tests should include liver enzymes, bilirubin levels, renal function tests (creatinine and electrolytes), and albumin levels. This will help guide treatment decisions.

2. Fluid Management: Given the severity of her ascites, paracentesis may be necessary to relieve discomfort and improve quality of life. This procedure can be performed safely, but it should be done under sterile conditions to minimize infection risk.

3. Diuretic Therapy: If diuretics are not effective, it may be worth discussing the possibility of adjusting dosages or trying different diuretics under the guidance of her healthcare team. However, caution is needed to avoid further kidney impairment.

4. Nutritional Support: A dietitian can help design a meal plan that is low in sodium and high in protein (if kidney function allows) to support liver health. Adequate protein intake is crucial for maintaining muscle mass and overall health.

5. Consideration of Dialysis: If kidney function continues to decline, dialysis may become necessary. While there is a risk of infection, especially in patients with ascites, the benefits of dialysis in managing fluid overload and electrolyte imbalances may outweigh the risks.

6. Multidisciplinary Approach: It is vital for her healthcare team to communicate effectively. Regular case discussions between her liver and kidney specialists can ensure that all aspects of her care are coordinated. This may involve case conferences or joint appointments where both specialists can address concerns together.

7. Liver Transplant Evaluation: Depending on her overall health status and the progression of her liver disease, she may be a candidate for liver transplantation. This decision would require careful evaluation of her liver function, kidney status, and overall prognosis.

8. Palliative Care: Given the advanced nature of her diseases, involving a palliative care team can help manage symptoms and improve her quality of life. They can provide support for both physical symptoms and emotional well-being.

In conclusion, managing ascites in the context of advanced liver disease and kidney failure requires a careful, individualized approach. Open communication with her healthcare providers and a commitment to regular follow-ups will be essential in navigating her complex health issues. It is important to advocate for her needs and ensure that her treatment plan is cohesive and comprehensive.

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