Paracentesis In Cirrhotic Patients Research Articles

S1322 Large Volume Paracentesis in Cirrhotic Patients With Acute Kidney Injury Is Not Associated With Worsening of Renal Function; Analysis of a Multi-Institutional Cohort

Introduction: Effect of large volume paracentesis on renal function in cirrhotic patients with ongoing acute kidney injury has not been studied in detail, and large volume paracentesis (LVP) is often avoided in these patients due to concerns of worsening renal injury. We studied the association between volume removed on paracentesis and outcomes of acute kidney injury. Methods: We performed a retrospective cohort study of patients at two institutions. IRB approval was obtained at both institutions. Patients with acute kidney injury at the time of paracentesis were included in the study. A retrospective chart review was then performed, and variables of interest were collected. Data was then de-identified and then pooled for analysis. Results: One-hundred and sixty-two patients were included in the final cohort. The mean age of study participants was 61.10 years (SD: ±11.70); the population was predominantly male (63.6%). Alcohol was the most common etiology (43%), followed by NASH (30%). One hundred and eleven patients had Child C cirrhosis (68.5%). Pre-renal acute kidney injury was the most common etiology prior to paracentesis (51%); eighty-six patients had KDIGO stage 1 acute kidney injury while 37 patients and 39 patients had Stage 2 and Stage 3 respectively. Forty-eight participants (29.6%) experienced a worsening of creatinine after paracentesis. Large volume paracentesis (4L or greater) was performed on 81 patients while the rest had less than 4L removed; the groups were well matched with no statistically significant difference in baseline characteristics. There was no difference in the proportion of patients experiencing worsening of renal function after paracentesis, in the proportion of patients who experienced eventual complete resolution of acute kidney injury (p-value = 0.55), or in the proportion of patients that requirement renal replacement therapy (p-value = 0.51). Multivariable regression analysis was conducted incorporating age, gender, CKD, MELD-Na score, albumin administration, and amount of volume removed during paracentesis, revealing CKD as the only covariate significantly associated with worsening renal function after paracentesis (p-value = 0.003). Large volume removal during paracentesis was not associated with worsening of renal function (p-value = 0.61). Conclusion: Large volume paracentesis is not associated with worsening renal function, when compared to small volume paracentesis, in cirrhotic patients with pre-existing acute kidney injury.

Six-minute walk test before and after large-volume paracentesis in cirrhotic patients with refractory ascites: A pilot study

Background/AimsFunctional impairment is common among cirrhotic patients with refractory ascites, and improvement in functional impairment is an expected issue after paracentesis. The six-minute walk test (6MWT) is considered an objective test for functional activity. No published data have evaluated the 6MWT among cirrhotic patients with refractory ascites before and after large-volume paracentesis. The research aim was to assess the feasibility of performing the 6MWT among cirrhotic patients who had refractory ascites before and after large-volume paracentesis. Materials and MethodsThirty-one cirrhotic inpatients with refractory ascites were subjected to pulmonary function tests (forced expiratory volume in one second [FEV1], forced vital capacity [FVC], FEV1/FVC) and diffusion lung capacity for carbon monoxide (DLCO) before and 48 h after therapeutic large-volume paracentesis. Dyspnoea as assessed by the Borg scale and functional capacity as assessed by the 6MWT were also evaluated. ResultsPrior to paracentesis, the mean values of FVC and FEV1 were lower than the predicted values, and a significant increase was observed after paracentesis. There was improvement in the mean DLCO values after paracentesis (P < 0.05). Regarding the 6MWT, significant increases in the walked distance (6MWD) (310.7 ± 73 vs. 348.7 ± 72.3 m) and oxygen saturation after paracentesis (P = 0.001) were observed. Significant improvement in the dyspnoea scale also occurred after paracentesis (P = 0.001). A significant positive correlation between the 6MWD before paracentesis and serum albumin levels was demonstrated (r = 0.373, P = 0.039). ConclusionWe found a decrease in pulmonary function and the 6MWD in patients who had refractory ascites, which improved significantly following large-volume paracentesis. The 6MWT is useful in detecting impaired functional capacity among cirrhotic patients.

Adherence Rates to Recommended Guidelines for Paracentesis in Cirrhotic Patients at a Tertiary Care Center and Associated Complications

Introduction: Ascites is the leading cause of hospitalization in cirrhotic patients. The American Association for the Study of Liver Diseases (AASLD) provides guidelines regarding paracentesis. While many providers give platelets and fresh frozen plasma (FFP) prior to paracentesis, AASLD discourages this as its evidence in reducing bleeds or morbidity is lacking. Regarding albumin infusion, AASLD reports survival benefit if given after large volume paracentesis (LVP), fluid removal greater than 4-5L. Nonadherence to these recommendations may result in poor outcomes, such as volume overload and acute kidney injury (AKI). We describe the results of adherence to guidelines for LVP in cirrhotic patients at a tertiary care center in the hopes of providing quality improvement and improving overall survival. Methods: We retrospectively constructed an inpatient cohort of consecutive patients eligible for paracentesis admitted to MGUH from Jan 2011-Sept 2015 (Table 1). Eligible patients had 1 of 3 primary diagnoses- ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy (HE)- and a secondary diagnosis of cirrhosis. Cases of HE required ascites as a secondary diagnosis. The independent variable was chart reviewed, verifying receipt of any LVP during hospitalization. The primary outcome variable was receipt of IV albumin. Secondary outcomes included receipt of FFP or platelets; AKI; and inpatient mortality. The chi square test was employed for all analyses.Table: Table. Patient DemographicsResults: Of the 280 cases that met eligibility criteria, 177 had any paracentesis--119 were diagnostic and 58 were LVPs. When compared with diagnostic paracentesis, receipt of LVP was associated with receipt of IV albumin (p<0.001). However, only 64% of patients undergoing LVPs received albumin. LVP was not associated with receipt of blood products. Of patients undergoing LVP, 22.2% and 17.3% received FFP and platelets respectively (Table 2).Table: No Caption availableConclusion: Our preliminary data shows room for improvement with regard to paracentesis and adherence to AASLD guidelines. IV albumin is not universally administered for LVPs; and potentially unnecessary blood products are being administered in a minority of patients undergoing paracentesis. Improved adherence to guidelines could result in fewer cases of volume overload and post-LVP AKI. Future safety interventions aimed at optimizing inpatient paracentesis practice can utilize these data as baseline to which post-intervention data can be compared.

Cost-effectiveness analysis comparing TIPS with large volume paracentesis in cirrhotic patients with refractory ascites

Cost-effectiveness analysis comparing TIPS with large volume paracentesis in cirrhotic patients with refractory ascites

Current position of vasoconstrictor and albumin infusion for type 1 hepatorenal syndrome.

Spontaneous bacterial peritonitis (SBP), refractory ascites, hepatorenal syndrome (HRS), hyponatremia and hepatic encephalopathy are complications which frequently happen during a clinical course of decompensated cirrhosis. Splanchnic and peripheral vasodilatation, increased intrarenal vasoconstriction and impaired cardiac responsive function are pathological changes causing systemic and hemodynamic derangement. Extreme renal vasoconstriction leads to severe reduction of renal blood flow and glomerular filtration rate, which finally evolves into the clinical feature of HRS. Clinical manifestations of type 1 and type 2 HRS come to medical attention differently. Patients with type 1 HRS present as acute kidney injury whereas those with type 2 HRS will have refractory ascites as the leading problem. Prompt diagnosis of type 1 HRS can halt the progression of HRS to acute tubular necrosis if the combined treatment of albumin infusion and vasoconstrictors is started timely. HRS reversal was seen in 34%-60% of patients, followed with decreasing mortality. Baseline serum levels of creatinine less than 5 mg/dL, bilirubin less than 10 mg/dL, and increased mean arterial pressure of over 5 mmHg by day 3 of the combined treatment of vasoconstrictor and albumin are the predictors of good response. Type 1 HRS can be prevented in some conditions such as albumin infusion in SBP, prophylactic antibiotics for upper gastrointestinal hemorrhage, albumin replacement after large volume paracentesis in cirrhotic patients with massive ascites. The benefit of albumin infusion in infection with primary source other than SBP requires more studies.

MELD Score and Albumin Replacement Are Related to Higher Costs During Management of Patients With Refractory Ascites

BackgroundAscites is the most common complication of cirrhosis and indicates that the disease is at an advanced stage. In cirrhotic patients with refractory ascites, treatment is based on repeat paracentesis. The objective of this study is to evaluate the cost of paracentesis in cirrhotic patients and to determine the factors related to this cost. MethodsThis prospective study included all patients with cirrhosis who underwent paracentesis between March 2012 and March 2013 at the Outpatient Service of the Liver Transplantation Unit, Clinical Hospital, University of São Paulo School of Medicine. Microcost analysis was performed with individual tabbed data regarding the consumption of albumin and containers for ascites. The remaining cost components were drugs, materials used during the procedure, and human resources. Statistical analysis was performed using SPSS version 20. ResultsWe conducted a total of 881 paracentesis procedures in a group of 155 patients that included 60.5% men and 39.5% women with a mean age of 57 years (range 20 to 80 years). Patients underwent an average of 5.3 paracentesis procedures per year (range 1 to 32). The total cost of all procedures was $193,126.60 and the most costly component was albumin ($87,162.10). The average cost per procedure was $219.50. The most frequent liver disease diagnoses were hepatitis C (24%) and alcoholic cirrhosis (24%). The majority of patients were on the liver transplant list (54.2%). Factors associated with higher costs in the period were a Model for End-Stage Liver Disease score higher than 24 (P = .001) and patients on the transplant waiting list (P = .042). ConclusionsParacentesis in cirrhotic patients is a high-cost procedure in health care. The main factors related to cost are the volume of fluid drained due to the need for albumin replacement and the severity of liver disease that is related to the frequency of paracentesis.

Respiratory impact of paracentesis in cirrhotic patients with acute lung injury

IntroductionAscites may contribute to the loss of lung volume and alter the gas exchange in cirrhotic patients with acute lung injury (ALI). AimThe aim of the study was to evaluate the effects of paracentesis on respiratory parameters in ventilated cirrhotic patients with ALI. Study DesignThis was a prospective trial in an intensive care unit of a university hospital. Patients and MethodsThirty-one cirrhotic patients on mechanical ventilation (with ALI) requiring paracentesis were included in this study. Arterial blood gases, intraabdominal pressures, ventilator parameters, and lung volumes were measured before and after the ascitic drainage. ResultsFollowing paracentesis, the intraabdominal pressure decreased (24.1 ± 7.0 vs 12.3 ± 8.9 mm Hg, P < .0001) and the Pao2/Fio2 improved significantly (190.0 ± 65.2 vs 284.9 ± 76.1 mm Hg, P < .0001), without hemodynamic disturbances. End-expiratory lung volume, markedly reduced before drainage, increased significantly following paracentesis (Δ end-expiratory lung volume: +463 ± 249 mL, P = .0009). No adverse effects related to the paracentesis were encountered. ConclusionIn contrast to ventilatory recruitment maneuvers, paracentesis is a simple and well-tolerated technique able to improve oxygenation and alveolar recruitment without the risk of the lung overdistension in severely hypoxemic cirrhotic patients.

Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial

Transjugular intrahepatic portosystemic shunt (TIPS) has recently been reported to be effective in the treatment of cirrhotic patients with refractory ascites. However, the clinical utility of TIPS in the subset of refractory ascitic patients with good hepatic and renal function is uncertain. The aim of this study was to compare the efficacy of TIPS to that of large-volume paracentesis in cirrhotic patients with refractory ascites who have good hepatic and renal function. Sixty cirrhotic patients with refractory ascites who presented with a Child-Pugh score of <11, serum bilirubin of <3 mg/dl and creatinine of <1.9 mg/dl were assigned randomly to TIPS (n = 30) or large-volume paracentesis plus albumin (n = 30). The primary endpoint was survival. The secondary endpoints were response to treatment and development of hepatic encephalopathy. The baseline characteristics were similar in the two groups. Seventeen patients treated with TIPS and 21 treated with paracentesis died during the study period. The cumulative probabilities of survival at 1 and 2 years were 80 and 64% in the TIPS group and 49 and 35% in the paracentesis group (p < 0.005). TIPS was significantly superior to paracentesis in the control of ascites (p < 0.005). Treatment failure was more frequent in the paracentesis group, whereas the frequency of hepatic encephalopathy was greater in the TIPS group. In cirrhotic patients with refractory ascites who have good hepatic and renal function, TIPS improves survival and provides better control of ascites than large-volume paracentesis.

Risk of Complications After Abdominal Paracentesis in Cirrhotic Patients: A Prospective Study

Complications and technical problems of paracentesis in cirrhotic patients are infrequent. However, the severity and the incidence of these events and their risk factors have not been assessed prospectively. Cirrhotic patients (n = 171) undergoing paracentesis were included. Of the 515 paracenteses, 8.8% were diagnostic, and 91.2% were therapeutic. Technical features, demographic data, and adverse events during a period of 72 hours after the procedure were examined. Major complications occurred in 1.6% of procedures and included 5 bleedings and 3 infections, resulting in death in 2 cases. Major complications were associated with therapeutic but not diagnostic procedures and tended to be more prevalent in patients with low platelet count (<50 10(9)/L), Child-Pugh stage C, and in alcoholic cirrhosis patients. Technical problems occurred in 5.6%. The most frequent complication was a leak of ascites at the puncture site (5.0%), and in 89.5% there were no complications. The safety of paracentesis in cirrhotic patients might be decreased if risk factors, which depend on the characteristics of the patient and of the procedure itself, are present.

Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites: A Meta-analysis of Individual Patient Data

Several randomized controlled trials have compared a transjugular intrahepatic portosystemic shunt (TIPS) with large-volume paracentesis in cirrhotic patients with refractory ascites. Although all agree that TIPS reduces the recurrence rate of ascites, survival is controversial. The aim of this study was to compare the effects of TIPS and large-volume paracentesis in cirrhotic patients with refractory ascites by means of meta-analysis of individual patient data from 4 randomized controlled trials. The study population consisted of 305 patients: 149 allocated to TIPS and 156 to paracentesis. Cumulative probabilities of transplant-free survival and of hepatic encephalopathy (HE) were estimated by the Kaplan-Meier method and differences assessed by log-rank test. The total number of HE episodes per patient was also compared between TIPS and paracentesis. Tense ascites recurred in 42% of patients allocated to TIPS and 89% allocated to paracentesis (P < .0001). Sixty-five patients in the TIPS group and 78 in the paracentesis group died. The actuarial probability of transplant-free survival was significantly better in the TIPS group (P = .035). Cox regression analysis performed in a subgroup of 235 patients (114 allocated to TIPS and 121 to paracentesis) showed that age, serum bilirubin level, plasma sodium level, and treatment allocation were independently associated with transplant-free survival. The average number of HE episodes was significantly higher in the TIPS group (1.13 +/- 1.93 vs 0.63 +/- 1.18; P = .006), although the cumulative probability of developing the first episode of HE was similar between the groups (P = .19). The present meta-analysis of individual patient data provides further evidence to the previous meta-analyses of literature data showing that TIPS significantly improves transplant-free survival of cirrhotic patients with refractory ascites.

The Role of Ascitic Paracentesis in Liver Cirrhosis in Improving the Function and Structure of the Heart

Background: Heart abnormalities in cirrhotic patients have been known for five decades, with atria and ventricular dilatation. Pozzi et al reported that in cirrhotic patients with or without ascites, the diastolic function was lower than control. Ascitic paracentesis improved diastolic function. The diameter of both atria was larger in cirrhotic patients with or without ascites. The diastolic diameter of left ventricle did not differ significantly in cirrhotic patients with or without ascites compared to control, but there was an increase after paracentesis. Ejection fraction was lower in cirrhotic and increased after ascitic parancentesis although the increase was not significant. The aim of the Study: To compare the function and structure of the heart before and after ascitic paracentesis in cirrhotic patients. Methods : This study took place from February 2000 to April 2001 in dr. Pringadi Hospital/H.Adam Malik Hospital. There were 18 samples (12 men and 6 women), 15 of which were cirrhotic patients with tense ascites and 3 cirrhotic patients with refractory ascites. The mean age was 51,8 + 8,28 years, the youngest being 29 years and the oldest 65 years. The mean ascitic fluid removed by paracentesis was 7,20 liters with a range of 5 to 9 liters. Immediately following paracentesis, Dextran 40 % was administered at a dose of 8g/ 1L ascitic fluid aspirated. Results : The diameter of the four heart chambers decreased after paracentesis, but the decrease was not statistically significant. There was increase in E/A ratio after ascitic paracentesis, from 0,93 + 0,370 to 1,06 + 0,383 (significant, p 0,05). Conclusion : After paracentesis, there was a significant improvement in diastolic function while the diameter of the four heart chambers decreased and the ejection fraction increased insignificantly. Keywords : Ascitic paracentesis - liver cirrhosis - heart function and structure.

Costs related to inappropriate use of albumin in Spain.

Albumin has been used in various treatments for > 50 years, but, recently, its use in clinical practice has become very controversial. To assess the use of albumin in clinical practice in the public hospital setting in Andalucía, Spain, focusing on the economic repercussions of the inappropriate use of albumin. Multicentered observational study in 22 public hospitals in which all patients receiving albumin (from start to conclusion of treatment) were assessed during a five-month period on three predetermined, nonconsecutive days. The clinical indications for albumin were evaluated on the basis of Guidelines, a consensus document created by a multidisciplinary team for dissemination by the Governmental Health Authority to all hospitals within its purview. The data were abstracted from the patient case report forms by the pharmacist selected to compile the data in each of the participating hospitals. A total of 242 forms reporting the use of 62,282 g of albumin were evaluated. The most frequent prescribing motives were nutritional intervention (23%), paracentesis in cirrhotic patients (19%), and radical surgery (11%). Only 59 prescriptions (24%), corresponding to 14,539 g of albumin (23%), were considered appropriate. The total cost of albumin therapy for the 242 cases was $183,796 (US$); $42,905 (23%) of this figure was the cost of appropriate use of albumin and $140,891 (77%) was the amount related to inappropriate use. Evaluated against model guidelines, the use of most of the albumin, deemed clinically necessary by the prescribers, was considered unnecessary or inappropriate. Hence, institutions need to define and implement guidelines that focus on responsible use of such agents in an increasingly cost-conscious healthcare environment.

Outpatient large volume paracentesis in cirrhotic patients with tenseascites: Safety and cost compared with an inpatient schedule

Outpatient large volume paracentesis in cirrhotic patients with tenseascites: Safety and cost compared with an inpatient schedule

Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia.

The safety of large-volume paracentesis with plasma expander infusion in ascitic cirrhotic patients with advanced liver disease, hyponatremia, or renal failure has not been elucidated. Our aim was to investigate the safety of total paracentesis in cirrhotic patients with ascites and severe hyponatremia. Forty-five cirrhotic patients with tense ascites were treated with total paracentesis and infusion of plasma expanders. At inclusion, 20 patients showed severe hyponatremia (serum sodium <130 mEq/L). In the remaining 25 patients, serum sodium was >130 mEq/L (range, 133-146 mEq/L). Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were significantly higher in patients with hyponatremia (PRA: 19.7 +/- 5.8 ng/mL/h; PAC: 217 +/- 35 ng/dL) than in those patients without hyponatremia (PRA: 4.9 +/- 1.1 ng/mL/h; PAC: 95 +/- 31 ng/dL), indicating a more severe systemic hemodynamic deterioration. After paracentesis, PRA and PAC increased similarly in both groups of patients. Serum sodium levels remained unchanged after paracentesis in patients with hyponatremia (127 +/- 0.5 to 128 +/- 1.5 mEq/L) and decreased slightly in patients without hyponatremia (137 +/- 1 to 135 +/- 1 mEq/L; p < 0.005). The incidence of complications during the first hospitalization, the probability of readmission for complications of cirrhosis, and the probability of survival at 1 yr were similar in both groups of patients. These results indicate that therapeutic paracentesis is a safe treatment for tense ascites in cirrhotic patients with severe hyponatremia.

Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia

OBJECTIVE: The safety of large-volume paracentesis with plasma expander infusion in ascitic cirrhotic patients with advanced liver disease, hyponatremia, or renal failure has not been elucidated. Our aim was to investigate the safety of total paracentesis in cirrhotic patients with ascites and severe hyponatremia. METHODS: Forty-five cirrhotic patients with tense ascites were treated with total paracentesis and infusion of plasma expanders. At inclusion, 20 patients showed severe hyponatremia (serum sodium <130 mEq/L). In the remaining 25 patients, serum sodium was >130 mEq/L (range, 133–146 mEq/L). RESULTS: Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were significantly higher in patients with hyponatremia (PRA: 19.7 ± 5.8 ng/mL/h; PAC: 217 ± 35 ng/dL) than in those patients without hyponatremia (PRA: 4.9 ± 1.1 ng/mL/h; PAC: 95 ± 31 ng/dL), indicating a more severe systemic hemodynamic deterioration. After paracentesis, PRA and PAC increased similarly in both groups of patients. Serum sodium levels remained unchanged after paracentesis in patients with hyponatremia (127 ± 0.5 to 128 ± 1.5 mEq/L) and decreased slightly in patients without hyponatremia (137 ± 1 to 135 ± 1 mEq/L; p < 0.005). The incidence of complications during the first hospitalization, the probability of readmission for complications of cirrhosis, and the probability of survival at 1 yr were similar in both groups of patients. CONCLUSIONS: These results indicate that therapeutic paracentesis is a safe treatment for tense ascites in cirrhotic patients with severe hyponatremia.

Time course of circulatory and humoral effects of rapid total paracentesis in cirrhotic patients with tense, refractory ascites

Background/Aims: Tense ascites of cirrhosis can be treated with total paracentesis; however, the short-term effects of this procedure are poorly defined. Methods: The circulatory and humoral changes induced by total paracentesis (250 mL/min) were studied in 12 cirrhotics with tense, refractory ascites. Data were collected before, during, and after paracentesis and 24 hours later (after albumin infusion). Hormonal parameters were recorded again 48 hours and 6 days thereafter. Results: Paracentesis (10.7 ± 4.4 L; 64 ± 20 minutes) caused marked reduction of intra-abdominal, intrathoracic, right atrial, and pulmonary pressures. Heart rate did not change. Cardiac output and heart volumes increased. Systemic vascular resistances and mean arterial pressure slightly decreased. Baseline plasma renin and aldosterone levels were markedly increased; a reduction was already evident during paracentesis with the lowest values at the end of the procedure. All changes were maintained 24 hours later. Hormones regained baseline levels 6 days later. Conclusions: Rapid total paracentesis is accompanied by marked cardiovascular and humoral changes. Some of these changes can be explained by mechanical factors that are directly or indirectly related to the relief of abdominal pressure. However, other changes (systemic vasodilatation, humoral deactivation) have a nonmechanical nature and may depend on reflexes originating from cardiac volume receptor stimulation. Most changes may beneficially (albeit transiently) influence the cardiovascular system of cirrhotic patients with tense ascites.

Predictive factors for hypovolemia after total paracentesis in cirrhotic patients with ascites

Predictive factors for hypovolemia after total paracentesis in cirrhotic patients with ascites

The therapeutic use of albumin

In this review, we condense and summarize the results of studies on the therapeutic use of human albumin to promote the more efficient use of this costly resource. Reports of major controlled and uncontrolled therapeutic trials, reviews, and summary articles published in English between 1972 and 1991 were identified through library and MEDLINE searches. Case series, prospective studies, and blinded therapeutic trials were identified from the bibliographies of these sources. All sources were critically evaluated for information about the comparative physiologic results and patient outcomes of the therapeutic use of albumin solutions, crystalloid solutions, and volume expanders other than albumin. The therapeutic use of albumin is of marginal benefit for many conditions for which it has been administered, apparently because of the body's capacity to quickly compensate for rapid colloid osmotic shifts. Human studies show little or no demonstrable value for albumin when it is administered for nutritional supplementation, wound healing, perioperative fluid replacement, treatment of early thermal injury, or therapy during extensive retroperitoneal surgery (including aortic aneurysm resection). Therapeutic albumin has well-defined value in several special circumstances: large-volume paracentesis in cirrhotic patients, acute nephrotic syndromes with diuretic resistance, organ transplantation, and plasmapheresis. Additional studies are needed to compare the efficacy of albumin with other volume expanders. For most purposes, balanced crystalloid solutions are satisfactory substitutes for colloid volume expanders and can be obtained at a fraction of the cost of colloid volume expanders.

Spontaneous Dialytic Ultrafiltration with Intraperitoneal Reinfusion of the Concentrate versus Large Paracentesis in Cirrhotic Patients with Intractable Ascites: A Randomized Study

Dialytic ultrafiltration of ascites through a hemofilter associated with peritoneal reinfusion (DUF) of the concentrate has been proposed for the treatment of refractory ascites. In five cirrhotic patients, 18 ascites evacuation procedures were randomized either to DUF (n = 8) or to large paracenteses (LP) (n = 10). The effects of these two methods on hemodynamic and renal function were assessed. After DUF, the protein concentration in ascites increased transiently from 28 +/- 7 g/l to 64.8 +/- 8 g/l (p less than 0.04); urinary output increased from day 1 to day 4 (1000 +/- 100) VS 1430 +/- 140 ml/24h; p less than 0.02). After LP, ascitic protein concentration and urinary output were unchanged. No side effects were observed with the two methods. The mean amount of albumin infused was 20 +/- 15 g after DUF and 15 +/- 5 after LP (ns).

Dextran administration avoids hemodynamic changes following paracentesis in cirrhotic patients. A safe and inexpensive option.

Paracentesis associated with albumin administration has been shown to be a safe and useful procedure in the treatment of patients with cirrhosis and ascites. Given the high cost of albumin, 20 patients with cirrhosis and ascites were treated in an open study, with daily paracentesis using dextran 70, an inexpensive volume expander, instead of albumin. In the first 10 patients, hemodynamic evaluation was performed in basal conditions, after each paracentesis (5 liter), and after dextran infusion. Twelve hours after each paracentesis without expansion, a significant drop in pulmonary capillary wedge pressure from 9.5 +/- 1.0 to 7.1 +/- 1.7 (P less than 0.01) and a reduction in cardiac output from 6.6 +/- 1.0 to 5.0 +/- 1.9 (NS) were observed. Moreover, the hematocrit rose significantly from 36.8 +/- 5.6 to 39.2 +/- 4.8 (P less than 0.01). These parameters returned to baseline values after the administration of 84 +/- 14 ml of dextran 70 for each 1000 ml of ascites removed. The other 10 patients received dextran 70 simultaneously with the paracentesis without hemodynamic control. No significant changes in renal and hepatic functions were observed at the end of the study. The mean volume of ascites removed was 12.3 +/- 4.6 liter. Two patients developed hyponatremia that required no treatment. No patient developed renal failure. One patient died because of gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)