Ascites Reinfusion Research Articles

Ascites reinfusion dialysis (ARD) for renal failure with refractory ascites

Dialysis is difficult for patients who have simultaneous liver and kidney failure. Effective mobilization of ascites is rare, and hypotension is common. Combining repeated paracentesis with continuous renal replacement therapy can achieve effective volume removal with hemodynamic stability, but requires intensive care unit resources. Large amounts of albumin are lost from the body in the drained ascites. Combining ascites reinfusion with hemodialysis is a potential alternative therapy. Eight treatments were undertaken in 3 patients with refractory ascites in the setting of acute onset renal failure. Hemodialysis was unsuccessful due to hypotension in each case. Two patients were treated twice, and 1 patient was treated 4 times. Each patient underwent hemodialysis with reinfusion of ascites directly into the blood inlet of the dialysis machine. Weight, blood urea nitrogen, albumin and platelet counts were measured before and after treatment. Hemodynamic tolerance was assessed, and patients were observed for the development ofencephalopathy, disseminated intravascular coagulation, infection and hemodynamic decompensation. All patients survived. There was 1 episode of transient hemoperitoneum, but no encephalopathy, GI bleeding or infection. One patient recovered renal function, and the other 2 were discharged ambulatory to chronic hemodialysis programs. Blood pressure was supported easily during therapy, despite removal of 3-8 kg of fluid. Platelet counts decreased by 27,000 +/- 13,000, and albumin increased by 0.5 +/- 0.2 g/dl. All values returned to baseline over the next 1-4 days. Ascites recirculation with dialysis is a safe and effective therapy for patients with refractory ascites and severe renal failure, which can be carried out in routine inpatient and outpatient settings. Hemodynamic tolerance was good and thrombocytopenia was modest.

Ultrafiltration in Diuretic-Resistant Volume Overload in Nephrotic Syndrome and Patients with Ascites due to Chronic Liver Disease

Patients with nephrotic syndrome and those with cirrhosis are predisposed to salt and water retention due to reduced renal sodium excretion. Despite the prescription of low-sodium diets and diuretics, some patients develop refractory oedema. When other medical treatments have been ineffective, isolated ultrafiltration and hemofiltration have been successfully used to treat refractory nephrotic patients. Following fluid removal, patients become responsive to diuretics. In cirrhotic patients, re-infusion of ascites and paracentesis with albumin infusion have been reported to be equally effective in managing ascites refractory to diuretic and other standard therapies. Although isolated ultrafiltration has not been successful in controlling ascitic fluid, hemofiltration has been shown to be beneficial, whereas standard intermittent hemodialysis has been reported to be ineffective.

腹水ろ過濃縮再静注法における腹水中ＩＬ‐６濃度と発熱との関係

腹水濾過濃縮再静注法は自己蛋白質の再利用であり資源の有効利用の面から有用な方法である. しかし副作用として高率に熱発, 悪寒を認め同方法の普及を妨げる一因となっている. 近年, 腹水中のIL-6が高値であることが報告され, 発熱にIL-6が関与している可能性が高いと考えた. 難治性腹水患者で腹水濾過濃縮再静注にて発熱を認めた5例について処理腹水中のIL-6濃度と静注後1時間, 2時間, 12時間 (一部24時間) において血中IL-6と体温の変化について検討を行った. 結果, IL-6血中濃度はいずれの症例においても静注開始後1時間で最高値を示し, 以降徐々に減少し, 12時間でほぼ治療前値に低下した. 体温は全症例において2時間値が最も高温であったが12時間後には治療前値に回復していた. 発熱物質のひとつとしてIL-6が有力である.

Paracentesis vs. intraperitoneal reinfusion of concentrated ascites — effect on opsonic activity of ascites

Background. Spontaneous bacterial peritonitis is a frequent and serious complication of cirrhotic ascites. An important defense mechanism of ascites against infection is opsonic activity, where the most important part is played by specific antibodies and C3 and C4 components of complement. The authors wanted to find out whether reinfusion of concentrated ascites or paracentesis can influence this activity. Methods. Twenty-six patients with cirrhosis of the liver and refractory ascites not corresponding to salt restriction and diuretics were divided into two groups. In 14 patients, a total of 25 therapeutic paracenteses were made; in 12 patients, a total of 19 reinfusions of concentrated ascites were performed intraperitoneally. In all patients, levels of IgG, IgA, IgM, C3 and C4 components of complement were assessed in ascites before and 24 h after the intervention. Results. After paracentesis no change of the investigated parameters was found. Reinfusion of concentrated ascites, on the other hand, led to a significant rise of IgG, IgA, IgM, C3 and C4 at the 0.5% level of significance. Conclusion. Treatment of refractory ascites by ultrafiltration and reinfusion intraperitoneally seems to increase opsonic activity of ascites and could be useful in the prevention of the development of spontaneous bacterial peritonitis.

Concentrated ascitic fluid reinfusion in cirrhotic patients: A simplified method

A new method for ascites filtration and reinfusion, which uses a single Cuprophan filter and is performed in the dialysis unit, is reported. Thirty-one procedures were performed in 17 patients with cirrhosis and massive ascites. A mean volume of 8.6 L of ascitic fluid was removed; from this volume, 5 L were ultrafiltered and a concentrated ascitic fluid was reinfused (x̄ = 359.8 mL). The whole procedure was completed in a mean time of 248 minutes. No relevant method-related complications were detected. Moreover, no significant changes in blood urea nitrogen (BUN), creatinine, plasma and urinary electrolytes, or platelet count were found, even in the case of repeated procedures (two to nine times). The reinfused fluid contained a mean value of albumin of 4.7 g/dL and significant amounts of globulins and complement. The overall cost of the materials used in the procedure ($49.46) offered competitive advantages with respect to other types of frequently used methods. In conclusion, we present a safe, effective, and time- and cost-saving technique for ascites reinfusion that represents an advantageous alternative to more complicated and expensive methods or to the currently used medical therapy.

Treatment of ascites: old and new remedies.

Ascites is a common complication of chronic liver disease. Treatment of the underlying liver disease with modalities such as abstinence from alcohol in Laennec's cirrhosis, phlebotomy in hemochromatosis, copper removal in Wilson's disease, and steroids in autoimmune liver disease, can improve survival in many patients. In addition, therapy of ascites alleviates the symptoms and improves the quality of life of the patients, and probably decreases the incidence of life-threatening conditions including spontaneous bacterial peritonitis and hepatorenal syndrome. The mean survival rate at 2 years is approximately 50%. Precipitating factors such as gastrointestinal bleeding, nonsteroidal anti-inflammatory drugs and infections, should be identified, since most of them can be corrected. Most cirrhotics with ascites can be managed with a 'step-by-step' approach, including dietary salt restrictions, aldosterone antagonists, and loop diuretics. When tense or refractory ascites is present, large-volume paracentesis is safe and effective. Peritoneovenous shunting (i.e. Denver, LeVeen) is less frequently used because of perioperative morbidity and mortality, and thrombotic complications with occlusion of the stent. Reinfusion of concentrated ascites is of potential benefit and has been used in Europe. Transjugular intrahepatic portosystemic shunt (TIPS) is an alternative procedure performed by interventional radiologists that allows decompression of portal hypertension. In many cases, ascites is improved after TIPS, but long-term randomized trials for tense or refractory ascites comparing TIPS with standard therapy are not conclusive. Liver transplantation is the ultimate step for the treatment of ascites, providing the cure for the underlying liver disease as well. Transplantation is indicated when quality of life of the patient is impaired due to recurrent episodes of ascites, or in the presence of spontaneous bacterial peritonitis and hepatorenal syndrome.

A simple method for ascites concentration and reinfusion

A rapid and simple method for ascites concentration and reinfusion was utilized to treat 103 episodes of tense ascites in 57 patients (38 men and 19 women, mean age 63 +/- 11 years). After a bedside total paracentesis, 6.06 +/- 2.87 liters of ascites were separately ultrafiltrated using a mechanical device during a mean interval of 134 +/- 88 min, and 430 +/- 368 ml of concentrate containing 39 +/- 42 g of albumin were restituted at bedside either intravenously (44 cases) or intraperitoneally (59 cases). Ultrafiltration was successfully and easily completed in all cases. Ascites concentration and reinfusion either intravenously or intraperitoneally did not adversely modify hemodynamic or renal parameters except for a transient decrease in mean arterial pressure (P < 0.05). Transitory hyponatremia and renal failure occurred in two patients. A transient decrease in platelet count and serum fibrinogen levels (P < 0.05) and pyrexia (12%) were observed only in patients reinfused intravenously. In conclusion, this new method for ascites concentration and reinfusion was effective, safe, and, with respect to traditional methods, simpler, faster and more comfortable. Therefore it is proposed for the routine management of tense ascites.

Ascites apheresis, concentration and reinfusion for the treatment of massive or refractory ascites in cirrhosis

A new method for ascites recirculation, consisting of a cellulose diacetate filter to remove substances with molecular weight > or = 300,000, cell debris and bacteria, followed by the concentration of ascitic fluid prior to i.v. infusion, was used 24 times in 19 patients with cirrhosis and massive or refractory ascites. The amount of ascites removed was 7.67 +/- 0.49 l, which was reduced to 407 +/- 37 ml. The procedure took 367 +/- 22 min to complete. No statistically significant changes in liver function tests, coagulative parameters, platelet count or natremia were found. The activity of coagulation and fibrinolytic systems was further assessed in six patients. No changes suggesting an activation of intravascular coagulation and/or primary fibrinolysis were disclosed. An asymptomatic fall in mean arterial pressure (from 88.6 +/- 2.6 to 80.3 +/- 3.0 mmHg; p = 0.02) occurred after paracentesis and was still present 48 h after ascites reinfusion. Plasma renin activity significantly decreased at the end of the procedure, but was not associated with a proportional reduction of plasma aldosterone concentrations. Both variables returned to baseline values 48 h later. A significant increase in the glomerular filtration rate occurred just after the end of the procedure (from 50.4 +/- 9.1 to 73.1 +/- 23.5 ml/min; p < 0.05) and subsided 48 h later. In contrast, no significant changes in diuresis and renal sodium excretion were found. Complications due to volume overload and sepsis did not occur; in one case, spontaneous bacterial peritonitis developed 3 days after the procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

Coagulopathy during ascites reinfusion: Prevention by antiplatelet therapy

The development of disseminated intravascular coagulation (DIC) during a controlled IV infusion of concentrated ascitic fluid was studied in a group of patients with cirrhosis and refractory ascites. Nine studies were performed on patients who had not received prophylactic antiplatelet therapy. All developed laboratory evidence of DIC. The total collagen infused, estimated by ascitic hydroxyproline concentration, correlated significantly with both the prolongation of the partial thromboplastin time with kaolin (r = 0.8628; P less than 0.005) and the decrease in platelet count (r = 0.5674; P less than 0.05). The changes in the coagulation profile were reversible on ceasing the infusion, returning to baseline levels within 12 hours. There were no changes in the coagulation profiles of four patients studied 48 hours after beginning antiplatelet therapy with aspirin and dipyridamole. It is concluded that the infusion of concentrated ascitic fluid into a peripheral vein of patients with cirrhosis results in DIC, the severity of which correlates with the amount of collagen infused and which is completely prevented by inhibiting collagen-induced platelet aggregation. The results support the hypothesis that the DIC that complicates ascites infusion into the systemic circulation is largely related to ascitic fluid collagen. (Gastroenterology 1992 Apr;102(4 Pt 1):1334-9)

Coagulopathy during ascites reinfusion: Prevention by antiplatelet therapy

The development of disseminated intravascular coagulation (DIC) during a controlled IV infusion of concentrated ascitic fluid was studied in a group of patients with cirrhosis and refractory ascites. Nine studies were performed on patients who had not received prophylactic antiplatelet therapy. All developed laboratory evidence of DIC. The total collagen infused, estimated by ascitic hydroxyproline concentration, correlated significantly with both the prolongation of the partial thromboplastin time with kaolin (r = 0.8628; P < 0.005) and the decrease in platelet count (r = 0.5674; P < 0.05). The changes in the coagulation profile were reversible on ceasing the infusion, returning to baseline levels within 12 hours. There were no changes in the coagulation profiles of four patients studied 48 hours after beginning antiplatelet therapy with aspirin and dipyridamole. It is concluded that the infusion of concentrated ascitic fluid into a peripheral vein of patients with cirrhosis results in DIC, the severity of which correlates with the amount of collagen infused and which is completely prevented by inhibiting collagen-induced platelet aggregation. The results support the hypothesis that the DIC that complicates ascites infusion into the systemic circulation is largely related to ascitic fluid collagen.

Prevention of the Febrile Reaction Occurring on Reinfusion of Cell-Free and Concentrated Autogenous Ascites.

The febrile reaction that occurs on reinfusion of ascites was studied. Intravenous reinfusion of ascites was performed 213 times in 63 cases of ascites, which were refractory to treatment with various drugs including diuretics. In order to prevent fever on reinfusion of ascites, a screen filter and a depth filter were used; the results were more favorable with the screen filter. Fibrin was considered to be one of the substances removable by the screen filter. HPLC analysis of the filtered and concentrated ascites, after passage through the screen filter, revealed a fraction corresponding to albumin. Intravenous injection of this fraction into rabbits caused fever. Although the screen filter cannot completely prevent fever on reinfusion of ascites, it appears useful to prevent fever in some patients.

Hemodynamic and renal effects of ascites apheresis and reinfusion in patients with cirrhosis

Hemodynamic and renal effects of ascites apheresis and reinfusion in patients with cirrhosis

An evaluation of combining reinfusing concentrated ascitic fluid and OK-432 therapy in patients with intractable malignant ascites.

We have performed a total of 356 intravenous reinfusions of ascites in 91 cases of malignant ascites encountered at our hospital. These patients were refractory to treatment with various drugs including diuretics. Ascitic drainage by paracentesis was performed in another 30 cases.The following findings were obtained: 1. Intravenous reinfusion of ascites was a more useful clinical therapy than drainage of ascites by paracentesis. 2. The therapeutic effect of intravenous reinfusion of ascites tended to be increased when it was combined with biological response modifiers (BRM) such as OK-432. 3. The combined administration of OK-432 with intravenous reinfusion of ascites was not so different between subcutaneous and intraperitoneal routes of administration. 4. The combination of anti-cancer agents with the intravenous reinfusion of ascites failed to improve the therapeutic effect. 5. Fever was the main side effect of this therapy. It was well tolerated with appropriate antipyretics.

Treatment of a dialysis patient with externaly intractable ascites by combination of ascites pump and reinfusion of concentrated ascites

Treatment of a dialysis patient with externaly intractable ascites by combination of ascites pump and reinfusion of concentrated ascites

A DIC-like picture on plasma and ascitic fluid of cirrhotic patients.

Ascitic fluid reinfusion in severe cirrhosis has frequently been associated with intravascular coagulation (DIC). A low-grade DIC has been postulated to be present in liver cirrhosis. PT, APTT, fibrinogen, plasminogen, antiplasmin, fibrin degradation producers (FDP), euglobulin lysis time, tissue plasminogen activator, and fibrinopeptide A were investigated both in the plasma and ascitic fluid of cirrhotic patients before and after the concentration-reinfusion technique. Our results indicate that increased thrombin formation associated with hyperfibrinolysis is present in the plasma of cirrhotic patients. In ascitic fluid very high levels of thrombin and fibrinolysis activation were found. We conclude that (1) a DIC-like picture exists in ascites and (2) after ascites reinfusion procedures, ascitic fluid is the principal factor in the pathogenesis of DIC. During ascitic fluid reinfusion heparin treatment could be used successfully.

Reverse Cascade Filtration of Ascitic Fluid-Preliminary Results

Refractory ascites is an infrequent complication of cirrhosis. Paracentesis and ultrafiltration of the ascitic fluid with intravenous or intraperitoneal reinfusion of the concentrated ascites has been used as therapy for this condition since 1971. The technique is cumbersome and has high morbidity and mortality rates, even if effective. In this paper we describe a new technique that couples secondary filtration for the removal of macromolecules, with ultrafiltration of ascitic fluid. In its very first application 6 patients underwent 8 treatments. No adverse effect was observed and clinical efficacy was good. Up to 60 g of albumin can be saved in a single session lasting less than 2 hours.

Fibrinolytic study in plasma and ascitic fluid of cirrhotic patients before and after ascites concentration; reinfusion technique

Management of cirrhosis with massive ascites involves particular difficulties. The introduction of a peritoneovenous shunt and reinfusion of concentrated ascitic fluid techniques allows increased diuresis and improves renal function. However, these procedures have frequently been associated with disseminated intravascular coagulation and/or activation of fibrinolysis. Factor VIII activity, antigen and ristocetin cofactor, plasminogen, antiplasmin, plasminogen activator activity and plasmin-antiplasmin complex were investigated both in the ascitic fluid and plasma of cirrhotic patients before and after the concentration-reinfusion technique. Our results indicated that no hyperfibrinolysis was seen in the plasma of cirrhotic patients and that activation of fibrinolysis exists in ascites. Significantly higher levels of plasmin-antiplasmin complex and plasminogen activator activity were found in ascitic fluid than in plasma. In post-reinfusion much higher levels of all three Factor VIII components were observed in cirrhotic plasma than in normal plasma. In conclusion, activation of fibrinolysis could explain coagulation complications occurring after ascites reinfusion. Antifibrinolytic treatment could render the concentration-reinfusion technique more acceptable.

TREATMENT OF INTRACTABLE ASCITES BY CONTINUOUS REINFUSION OF THE STERILIZED, CELL-FREE AND CONCENTRATED ASCITIC FLUID

The new method for continuous reinfusion of sterilized, cell-free and concentrated ascitic fluid is described, and utilized in 72 patients with intractable ascites in both malignancy as well as liver cirrhosis and is described with satisfactory results. The management by repeated ascites reinfusion of patients with benign massive ascites has been possible. This method is capable of being applied to patients with malignant ascites. Symptomatic relief and prolonged survival time is anticipated. The method described in this study is simple and free of adverse effects.

Ascites reinfusion using the Rhodiascit apparatus—clinical experience and coagulation abnormalities

Summary The results of twenty-four ascitic reinfusions in twenty patients, using the Rhodiascit procedure, are reported. The procedure was of no value in the management of patients with spontaneous functional renal failure, but was of considerable value in accelerating hospital discharge of patients with tense ascites but good renal function. Complications of the procedure were few, but tests of blood coagulation became abnormal, the most likely cause of which was deposition of fibrin on to the filtration membrane.

The Rhodiascit system--individual response to reinfusion possibly related to angiotensin sensitivity: preliminary results.

Summary Results are reported of the effect of ascites reinfusion with concentration in seventeen patients. Complications were few and best results were obtained when the patient was also given frusemide during the reinfusion. The diuretic response to the reinfusion appeared to be determined by the pre-existing sensitivity of the circulation to intravenously administered angiotensin.