Monday, June 3, 2019

diuretic resistant cirrhosis

Q:55 year old male with history of cirrhosis is admitted to ICU with hypotension, volume overload, and massive ascites. Patient is reported by his family to adherent to his medicines but lately, a new medicine was prescribed by his primary care physician. Addition of which of the following drugs is known to cause decrease diuretic responsiveness? 

A) Nonsteroidal antiinflammatory drug (NSAID) 
B) Midodrine 
C) Colloid
D) Vaptans 
E) Clonidine

Answer: A

NSAIDs are the inhibitors of renal prostaglandins, which leads to renal vasoconstriction, causing lesser response to diuretics.

Midodrine as an oral vasopressor increases blood pressure, and can be very useful in cirrhosis to improve renal perfusion.

Clonidine is helpful in diuretic resistant ascites. It is an alpha-2-adrenergic receptor agonist and suppresses the renin-aldosterone system, which are known to be activated in patients with diuretic-resistant ascites.

Colloid are indicated in cirrhosis.

Vaptans have been tried in cirrhosis but one of the vaptan (tolvaptan), is associated with liver injury, but not known to cause direct diuretic resistant cirrhosis.



1. Arroyo V, Ginés P, Rimola A, Gaya J. Renal function abnormalities, prostaglandins, and effects of nonsteroidal anti-inflammatory drugs in cirrhosis with ascites. An overview with emphasis on pathogenesis. Am J Med 1986; 81:104.

2. Runyon BA. Refractory ascites. Semin Liver Dis 1993; 13:343.

3. Singh V, Dhungana SP, Singh B, et al. Midodrine in patients with cirrhosis and refractory or recurrent ascites: a randomized pilot study. J Hepatol 2012; 56:348.

4. Boyer TD. Tolvaptan and hyponatremia in a patient with cirrhosis. Hepatology 2010; 51:699.

5. Singh V, Singh A, Singh B, et al. Midodrine and clonidine in patients with cirrhosis and refractory or recurrent ascites: a randomized pilot study. Am J Gastroenterol 2013; 108:560.

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