Metolazone in Diuretic Refractory Ascites

Background: Refractory ascites occurs in about 10% of patients with cirrhosis and ascites. Available treatment options are invasive and costly procedures with significant complication rates. We hypothesized that adding metolazone; thiazide like diuretic, to conventional diuretics in these diuretic refractory patients may convert them to a diuretic sensitive stage and promote natriuresis. We conducted a pilot study to examine the efficacy of metolazone in diuretic refractory ascites. Methods: Patients with refractory ascites were randomized to two groups. Group 1 received 10 mg of metolazone and Group 2 received 80 mg of furosemide. Both groups received their basal diuretic regimen. 24 hour urinary sodium was measured to compare the two groups. Results: Metolazone group increased their 24 hr sodium excretion by 127±150.4 meq as compared to 44.5± 32.6 meq in the furosemide group (p=0.1). Average increase in urine output in the metolazone group was 1513ml as compared to 457ml for furosemide group. Conclusion: Metolazone increased natriuresis by almost 3 times as compared to furosemide. Although the results were statistically not significant due to small sample size, these pilot observations indicate that further studies are needed to investigate role of metolazone in diuretic refractory ascites.