Using a large-scale claims database, we investigated the prevalence of ascites and diuretic use in 67,698 inpatients with liver cirrhosis. Ascites developed in 50.9% of patients, with the highest prevalence patients in with alcoholic hepatitis. The prescription rate of concomitant spironolactone and furosemide decreased and that of tolvaptan with both diuretics increased from 2013 to 2018. Tolvaptan tends to be prescribed in patients with more severe symptoms. After tolvaptan was approved for volume overload in liver cirrhosis in 2013, the furosemide dose concomitantly prescribed with tolvaptan was annually increased at a dose ≤20 mg/day and decreased at a dose >40 mg/day. Ascites developed in >50% of inpatients with liver cirrhosis, particularly those with alcoholic hepatitis, and diuretics were prescribed in clinical settings as per the Japanese guidelines. Our findings emphasize the importance of enhanced awareness on promoting abstinence and/or reducing alcohol consumption for the prevention of liver cirrhosis.

A 72-year-old man was admitted to our hospital with complaints of general fatigue and abdominal swelling. Based on laboratory and imaging examinations, he was diagnosed with liver cirrhosis (complicated with hepatocellular carcinoma) and liver failure due to primary biliary cholangitis with positive anti-mitochondria M2 antibody and increased immunoglobulin M levels. Serum anti-hepatitis E virus (HEV) immunoglobulin A and HEV RNA were also positive, suggesting the diagnosis of acute-on-chronic hepatic exacerbation caused by HEV infection. After admission, although HEV RNA became undetectable, the patient died of rupture of hepatocellular carcinoma. During the observation period of 78 days, the titers of anti-HEV IgM, IgG, and IgA antibodies were relatively low and nearly unchanged. In cases of acute-on-chronic hepatitis, HEV infection should also be considered as a cause of hepatic exacerbation. Atypical dynamics of HEV antibodies observed in the present case warrants further examinations in HEV-infected patients with cirrhosis.

Harm reduction by reducing alcohol consumption, which has been used as a treatment of alcohol dependence, has now gained recognition in Japan. Nalmefene is currently approved in Japan to reduce alcohol consumption in alcohol-dependent patients.

A 61-year-old man diagnosed with alcoholic cirrhosis 2 years ago was admitted to our hospital for abdominal distension and leg edema. At the time of admission, abdominal CT showed massive ascites, consistent with cirrhosis. Ascites and leg edema were gradually improved by diuretic therapy using tolvaptan and conventional diuretics. However, he resumed alcohol drinking 4 months after abstinence. Therefore, we proposed harm reduction therapy, and he was treated with nalmefene and abstinence from alcohol. Therefore, nalmefene may be a valuable pharmacological treatment option for alcohol-dependent patients who are either not ready or unable to consider complete abstinence as the initial treatment goal or have not undergone any treatment.