In cirrhotic patients with ascites, what is first-line medical management?

• A. Furosemide
• B. Sodium restriction and diuretics (often spironolactone, with or without furosemide)
• C. Mannitol
• D. Hydrochlorothiazide

Answer: (B)

In cirrhosis with ascites, the main issue is kidneys holding on to sodium due to secondary hyperaldosteronism from reduced effective blood volume. The best first-line approach is to reduce sodium intake and use a diuretic strategy that counteracts aldosterone-mediated Na reabsorption. Spironolactone, a potassium-sparing aldosterone antagonist, directly blocks aldosterone in the distal nephron, promoting sodium and water excretion while preserving potassium. This targets the driving mechanism of volume overload in these patients, making it the most effective starting therapy. If diuresis is insufficient or volume status requires it, furosemide can be added to enhance natriuresis, but relying on a loop diuretic alone without addressing aldosterone-driven retention is less effective in this setting.

Mannitol is not used for ascites management and hydrochlorothiazide alone doesn’t address the key pathophysiology, so they aren’t first-line choices. Monitoring is important: track electrolytes (potassium, especially on spironolactone), renal function, and volume status, and adjust therapy to avoid overdiuresis or hyperkalemia.