In cirrhosis with ascites, what is the standard diuretic strategy?

• A. Sodium restriction with loop diuretic
• B. Mannitol
• C. Furosemide alone
• D. Sodium restriction with spironolactone

Answer: (D)

In cirrhosis with ascites, the main problem is Na and water retention driven by increased aldosterone activity from reduced effective arterial blood volume. The standard diuretic strategy targets this hormonal driver by using an aldosterone antagonist and restricting dietary sodium. Spironolactone blocks aldosterone receptors in the distal nephron, reducing sodium reabsorption and promoting water excretion while conserving potassium. When combined with sodium restriction, this directly counters the mechanism behind ascites and is more effective and safer as initial therapy than relying on a loop diuretic alone or an osmotic diuretic. If additional diuresis is needed after several days, a loop diuretic can be added with careful monitoring, but the foundation remains sodium restriction plus spironolactone.