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09/08/2011 - diuresis in cirrhosis

posted Sep 28, 2011, 5:49 PM by Chief Resident   [ updated Sep 28, 2011, 5:51 PM by Purnema Madahar ]
An interesting claim from resident report which can be found in the attached AASLD guideline on the management of ascites in cirrhotics:

Managment of cirrhotic ascites relies on dietary sodium restriction to 2g/day (88mmol/day) and diuretics. The prefered diuretic regimen is a combination of spironolactone and furosemide in a 100:40 ratio. The goal of diuretic therapy is to increase urinary sodium excretion to more than 78mmol/day in a patient adherent to the above dietary restrictions (88mmol intake - 10mmol non-urinary losses). The gold standard for this measurement would be a 24 hour urine collection, which is oftentimes impractical.

The guideline states: 'A random spot urine sodium concentration that is greater than the potassium concentration correlates with a 24-hour sodium excretion greater than 78 mmol/day with approximately 90% accuracy. This urine sodium/potassium ratio may replace the cumbersome 24-hour collection.'

In other words, 9 out of 10 times you would correctly identify patients that either don't meet the diet restrictions or need higher doses of diuretics to achieve a negative sodium balance.

A very important caveat that's generalizable to most guidelines and morning reports: the citation supporting this particular statement leads to an abstract that was not indexed in Medline and can't be retrieved from the journal's website. This is also known as expert opinion. Beware.

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