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.     

Plasma atrial natriuretic factor in cirrhotic patients with ascites. Effect of peritoneovenous shunt implantation

Human atrial natriuretic factor (ANF) levels were measured before and after peritoneovenous shunt implantation in 10 cirrhotic patients with ascites, in whom sodium retention is a major clinical problem. The mean preoperative plasma level of ANF was 82 ng/L (normal range, 5-80 ng/L). Peritoneovenous shunting resulted in a significant rise in plasma ANF to 308 ng/L (p less than 0.0025) immediately after operation. This was followed by a constant fall until the seventh postoperative day, when mean plasma ANF was still significantly elevated (149 ng/L) compared with the preoperative value (p less than 0.01). Three months after shunt implantation mean plasma ANF had returned to the preoperative level (75 ng/L). Mean sodium excretion increased from 2.6 mEq/h preoperatively to 10.2 mEq/h at the second postoperative day (p less than 0.025). No direct relationship was noted between changes in plasma ANF level and changes in urinary sodium excretion after shunt implantation. These data demonstrate an intact ANF release response to intravascular volume expansion in cirrhotic patients with ascites, but exclude ANF as the diminished natriuretic factor as proposed by the overflow theory of ascites formation. Sodium excretion and fluid retention seem to be the result of vascular underfill and fluid maldistribution, and hormonal changes are likely to be secondary to them.     

Prospective study comparing human albumin vs. reinfusion of ultrafiltrate-ascitic fluid after total paracentesis in cirrhotic patients with tense ascites

Although, total paracentesis associated with human albumin substitution has shown to be a rapid, effective and safe treatment of diuretic refractory ascites in advanced liver cirrhosis, it implies high costs and has a limited availability. Therefore an alternative procedure the reinfusion of concentrated ascites has gained popularity in recent years (Smart et al. 1990; Grazioto et al. 1997). It was the aim of the study to compare human albumin substitution vs. reinfusion of ascitic-ultrafiltrate after total paracentesis. 35 patients with cirrhosis and tense ascites received total paracentesis associated with either human albumin (5-8 g/l ascites) (= group A) or reinfusion of an ascitic-ultrafiltrate fluid by means of hemofiltration technique (= group B). The mean volume of ascites removed was 9.41 (2.1-20.0) in group A and 11.41 (6.5-21.0) in group B. No significant differences in serum electrolytes, liver and renal function, coagulation profiles and hormones of the renin-angiotensin-aldosterone system were observed during hospitalization. In both groups sodium excretion increased significantly. 43% of the patients in group B developed pyrexia and chill after reinfusion of the ascitic-ultrafiltrate fluid. In one patient an anaphylactic bronchospasm occurred requiring IUC-treatment. The treatment cost in case of human albumin were 326.-DM vs. 290.-DM for each patient treated with ascitic-ultrafiltrate fluid reinfusion. The probabilities of hospital readmission and survival were similar in both groups during follow-up. The results indicate that i.v. infusion of ascitic-ultrafiltrate fluid is as effective as total paracentesis and albumin infusion in case of diuretic refractory ascites. However, according to the costs of instruments and staff and due to the significant allergic reactions caused by ascitic fluid it cannot be considered as a real alternative to albumin substitution.     

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.     

Dextran-70 versus albumin as plasma expanders in cirrhotic patients with tense ascites treated with total paracentesis. Results of a randomized study.

To investigate whether albumin can be substituted by less expensive plasma expanders in cirrhotic patients with tense ascites treated with total paracentesis, 88 patients (16 with renal failure) submitted to this therapeutic procedure were randomly assigned to receive IV albumin (43 patients) or dextran-70. Both substances were given at a dose of 8 g/L of ascitic fluid removed. Patients were discharged from the hospital with diuretics, and cases developing tense ascites during follow-up were treated according to their initial schedule. Total paracentesis was effective in eliminating the ascites in all but two cases in each group. Neither paracentesis plus IV albumin infusion nor paracentesis plus IV dextran-70 infusion was associated with significant changes in renal and hepatic function or serum electrolytes. The incidence of renal impairment (one case in each group), hyponatremia (three and four cases, respectively), and other complications (hepatic encephalopathy, gastrointestinal hemorrhage, bacterial infections) after paracentesis, and the clinical course of the disease as estimated by the probability of readmission to hospital during follow-up, causes of readmission, probability of survival, and causes of death were similar in the two groups of patients. The effect of paracentesis on effective intravascular volume was indirectly assessed by measuring plasma renin activity and aldosterone concentration before and 2 and 6 days after treatment, the patients being without diuretics. In patients treated with albumin, no significant changes in renin and aldosterone were observed during the entire period of observation. In contrast, both parameters increased significantly on the 6th day of treatment in patients receiving dextran-70. A significant increase in plasma renin activity and aldosterone concentration (30% over baseline values) was observed in 51% of patients treated with dextran-70 and in only 15% of those treated with albumin (x2 = 10.4; P = 0.0012). These results indicate that although dextran-70 is less efficacious than albumin in protecting cirrhotic patients treated with total paracentesis from the decrease in effective intravascular volume, it appears to be capable of preventing the renal and electrolyte complications induced by this therapeutic procedure.     

Large-volume paracentesis in nonedematous patients with tense ascites: its effect on intravascular volume

In patients with portal hypertension and tense ascites, large-volume paracentesis improves patient comfort and may improve systemic hemodynamics. However, it has been avoided in nonedematous patients because of concern for complications, including intravascular volume depletion. In this study, 12 nonedematous patients with chronic liver disease, portal hypertension and tense ascites underwent 14 large-volume (5-liter) paracenteses for the relief of discomfort and/or respiratory distress. Plasma volume was measured directly by a dilution method with 125I-labeled human serum albumin prior to and at 24 or 48 hr after 13 of the paracenteses. All patients felt better postparacentesis. No dizziness, hypotension, tachycardia, encephalopathy or change in mean serum sodium, creatinine or blood urea nitrogen occurred. Two patients experienced a decrease in hematocrit, which was not explained by blood loss or increase in plasma volume. Mean plasma volume was 3,713 +/- 129 ml (55.1 +/- 1.5 ml per kg ideal body weight) preparacentesis and 3,684 +/- 136 ml postparacentesis, the difference being -0.78% (p = 0.48, NS). Our results suggest that 5-liter paracentesis in nonedematous patients with tense portal hypertension-related ascites improves patient comfort and is not associated with a decrease in measured plasma volume.     

Treatment of cirrhotic tense ascites with Dextran-40 versus albumin associated with large volume paracentesis: a randomized controlled trial

Intravenous albumin infusion prevents complications after large-volume paracentesis (LVP), particularly paracentesis-induced circulatory dysfunction (PCD), and improves patient survival. However, albumin is expensive. We compared a low-molecular weight dextran (Dextran-40) with albumin in treating LVP in cirrhotic patients with tense ascites. Sixty-nine cirrhotic patients were included and 96 LVPs were performed. Any repeat punctures on the same patient were at least three months apart. Patients were randomized to receive either i.v. Dextran-40 infusion (Group I, n = 48) or i.v. albumin infusion after LVP (Group II, n = 48). Clinical, biochemical, and hormonal evaluations were done before and after LVP. Patients were followed up for the detection of any recurrence of ascites or complications. The two groups were similar in age, sex, and etiology of cirrhosis, and in the volumes of ascites recovered. Significant decreases in mean arterial pressure were observed in both groups 24 and 48 h after LVP. Urine volumes increased significantly at 24 h in both groups (p < 0.05), but remained high only in Group I. Plasma renin activity and aldosterone concentrations increased in both groups 48 h after LVP, but they were more marked in Group I. Complications developed in 17 % of patients treated with Dextran-40 and in 23 % treated with albumin (p > 0.05). Ascites recurrence rates and survival were similar in the two groups. In conclusion, Dextran-40 was thus not as efficacious as albumin for preventing PCD.     

Large volume paracentesis and intravenous dextran to treat tense ascites.

Forty patients with cirrhosis of the liver and tense ascites were randomized to receive either aldactone 400 mg/day and furosemide 80 mg/day (n = 20) or repeated large volume paracentesis (LVP) and infusion of low molecular weight dextran (n = 20). Both treatment groups were similar in clinical and laboratory parameters. Complete mobilization of the ascitic fluid was achieved in all receiving LVP and dextran therapy within 1 week of the treatment, in contrast to the minimal mobilization of the ascitic fluid in patients receiving diuretics even after 2 weeks of therapy. Renal function, the clinical parameters of systemic hemodynamics, serum electrolytes, and hepatic function remained stable in patients receiving LVP and dextran and were similar to those in the diuretic-treated patients. We found no deterioration of these functions in the nonedematous patients treated by LVP and dextran even though the protective effect of edema against LVP was lacking in them. Plasma volume estimation in six nonedematous cirrhotic patients treated by LVP and dextran did not reveal any hypovolemia after complete mobilization of ascites. The frequency of complications and death were similar in the two groups. Dextran infusion is a safe, effective, and low-cost replacement therapy in patients with cirrhotic ascites treated by LVP.     

Unilateral leg edema in a cirrhotic patient with tense ascites

TO THE EDITOR A 61 year old man with cirrhosis and hepatocellular carcinoma developed on the background of chronic hepatitis B was admitted because of acute and gradually intensified right thigh pain and swelling, which, within a few hours, was expanded to his right foot. The patient,due to ascites refractory to diuretics, was almost weekly subjected to large volume paracentesis of ascitic fluid for the last six months; meanwhile he has developed a left inguinal, a right femoral and an umbilical hernia. It should be noted that 48 h before admission, the patient was referred to the emergency room because of dyspnoea and 5 L of ascitic fluid were removed.     

Central venous pressure catheter for large-volume paracentesis in refractory ascites

Background and Aims

About 10 % of cirrhotic patients are unresponsive to sodium restriction and diuretics and develop refractory ascites. Such patients usually require recurrent large-volume paracentesis and lots of hospital admissions. Hereby, we introduce a method applying a central vein (CV) catheter for large-volume paracentesis in patients with refractory ascites in up to 4 days associated with sodium restriction and high dose of diuretics.

Methods

Non-tunneled triple lumen CV catheter was used to drain the ascites fluid of 30 cirrhotic patients. After precise percussion, the point of highest fluid accumulation was marked for puncture. Then, the skin and subcutaneous tissue were anesthetized. CV catheter set guide wire was entered into the peritoneal cavity and the dilator of the CV catheter set was passed through the guide wire and extracted after some rotations around its insertion site on the skin. The catheter was passed over the guide wire and the guide wire was extracted gradually from one of the lumens and fixed to the skin.

Results

Nineteen males and 11 females with mean (±SD) age of 59.4?±?11.7 years old underwent the procedure. A minimum of 9 and maximum of 29 L (12?±?6.6 L) ascites fluid drained during a minimum of 2 and maximum of 5 days of hospital stay. All catheters were patent during the drainage. None of the patients developed hemodynamic instability. Number of re-hospitalizations for paracentesis was 1.9 times during the following year. No complication occurred.

Conclusions

This technique is a simple noninvasive method that can be performed in the endoscopy unit or even at the patient’s bedside and may reduce the need for repeated admissions.     

术前穿刺置管持续腹水引流对肝硬化伴顽固性腹水患者肝移植效果的影响

目的 评价术前穿刺置管持续腹水引流对拟行肝移植的肝硬化伴顽固性腹水患者肝移植效果的影响.方法 将2003年2月-2005年12月在我院行肝移植术的肝硬化伴顽固性腹水患者随机分为对照组(单纯药物治疗)和实验组(术前加穿刺置管腹水引流),分析治疗效果,并对肝移植疗效(包括随访)进行比较.结果 实验组穿刺置管腹水引流操作中无并发症发生,治疗后症状缓解率明显高于对照组,体重降低,尿量增加,尿蛋白降低,移植后半年血肌酐明显低于治疗前.对照组治疗后较治疗前MELD评分分值显著性升高.结论 术前穿刺置管持续腹水引流技术安全稳定,相比单纯药物治疗,综合治疗能够提高肝硬化伴顽固性腹水患者的术前状况.     

Treatment of ascites in cirrhosis. Diuretics, peritoneovenous shunt, and large-volume paracentesis.

The medical treatment of ascites in cirrhosis is based on sodium restriction and the administration of diuretics. Because the natriuretic potency of spironolactone is greater than that of loop diuretics (i.e., furosemide) in patients with marked sodium retention, spironolactone is the basic drug for the treatment of ascites. The simultaneous administration of spironolactone and furosemide increases the natriuretic effect of each drug and diminishes their effects on potassium metabolism. Recent studies indicate that large-volume paracentesis associated with intravenous albumin infusion is more effective than diuretic therapy in eliminating the ascitic fluid; is associated with a lower incidence of complications (hepatic encephalopathy, renal impairment, and hyponatremia); and considerably reduces the duration of hospital stay. Therapeutic paracentesis associated with intravenous albumin infusion is therefore the treatment of choice for cirrhotic patients with tense ascites. The mobilization of the ascitic fluid by paracentesis without plasma volume expansion is constantly associated with a deterioration of effective circulating blood volume and may induce renal impairment and severe hyponatremia. Dextran 70 and polygeline appear as effective as albumin in preventing these abnormalities. Cirrhotic patients treated with paracentesis require the administration of diuretics to avoid reaccumulation of ascites. Peritoneovenous shunt, a prosthesis capable to correct most abnormalities involved in the accumulation of fluid in the abdominal cavity, is an effective treatment of ascites in cirrhosis. It is especially indicated in patients who do not respond to diuretics and develop repeated episodes of ascites despite adequate treatment. The use of peritoneovenous shunting is limited by the high incidence of complications induced by the procedure, however. In addition, approximately 40% of patients develop an obstruction of the prosthesis within the first postoperative year.     

Effect of sinorphan, an enkephalinase inhibitor, on plasma atrial natriuretic factor and sodium urinary excretion in cirrhotic patients with ascites.

We examined the acute effects of sinorphan, an inhibitor of enkephalinase, on plasma atrial natriuretic factor (ANF) and urinary sodium excretion in cirrhotic patients with ascites. A single oral dose of sinorphan (100 or 30 mg in 11 and 5 patients, respectively) was administered against placebo according to a double blind cross-over protocol. Basal plasma ANF levels varied over a large range between 2.6-79 pmol/L. Sinorphan, at a dose of 100 mg, inhibited 70% of plasma enkephalinase activity 60 min after ingestion and elicited simultaneously an increase in plasma ANF and cGMP levels 1.8 and 1.5 times basal values, respectively. There was a transient increase in sodium urinary output without a change in creatinine clearance over the initial 2-h period following drug administration. An increase in urinary cGMP was also observed on a longer period of 6 h. Plasma aldosterone decreased significantly, but the lowest concentration was reached 1 h later than the peak of plasma ANF. Mean blood pressure and PRA were unmodified. The effects of 30 mg sinorphan on plasma ANF, cGMP, and aldosterone were also significant, but less marked than those of the higher dose. Therefore, enkephalinase inhibition transiently increases sodium urinary excretion in cirrhotic patients with ascites via a mechanism that is likely to imply reduction of ANF catabolism. These results suggest that ANF could play a role in the control of sodium homeostasis in liver cirrhosis with ascites.     

Randomized comparative study of hemaccel vs. albumin infusion after total paracentesis in cirrhotic patients with refractory ascites.

Fifty-four cirrhotic patients with refractory ascites were treated with one-session large-volume paracentesis and randomly assigned to two groups. The first group was infused with human albumin, and the second group was infused with hemaccel at doses with comparable oncotic power. The two groups were compared for incidence of complications, recurrence of massive ascites after hospital dismissal and survival rate. The incidence of complications traditionally related to paracentesis, the probability of requiring readmission to the hospital for ascites (p = 0.48) and the probability of survival after entry into the study (p = 0.85) were the same for the two groups. A multivariate analysis of 16 parameters, including treatment modality, identified absolute unresponsiveness to diuretics as the only independent predictor of mortality. These results indicate that hemaccel infusion may safely replace albumin infusion after total paracentesis for cirrhotic patients with refractory ascites.     

Total therapeutic paracentesis (TTP) with and without intravenous albumin in the treatment of cirrhotic tense ascites: a randomized controlled trial

ABSTRACT— We studied 35 cirrhotic patients with tense ascites assigned at random into two groups: Group I consisted of 17 patients treated by total therapeutic paracentesis (TTP) (6–15 1) plus i.v. albumin (5 g/l of fluid) and Group II consisted of 18 patients treated by TTP (5.5–15.5 1) without albumin. On 19 patients we performed a sequential assessment of cardiac output (CO), plasma renin activity (PRA) and plasma aldosterone (PA). Both groups were similar in age, sex, and etiology of cirrhosis. CO, PRA and PA values were expressed as mean changes occurring in relation to their respective baseline values. CO changes after TTP (1/min): Group I: 2.5 after 6 h and 2.2 after 12 h; Group II: 2.2 after 6 h and –0.4 after 12 h, (p<0.05 comparing values after 12 h between the two groups). PRA changes after TTP (ng/dl/h): Group I: –7.4 after 1 h, –7.8 after 6 h and –3.2 after 24 h; Group II: –2.4 after 1 h, –0.8 after 6 h and 3.9 after 24 h (p<0.05 comparing values between both groups after 6 and 24 h). PA changes after TTP (ng/dl): Group I: –50.5 after 1 h, –36.7 after 6 h and –34.6 after 24 h; Group II: –18.2 after 1 h, –2.2 after 6 h and 20 after 24 h, (p < 0.05 comparing values between both groups after 1 and 6 h). Complications were minimal in both groups. In conclusion, there was an increase of CO and a decrease of PRA and PA in all patients early after TTP. However, after 6 h there was a decrease of CO and an increase of PRA and PA, suggesting hypovolemia, only in patients without albumin. The frequency of complications after 24 h was similar in both groups. Since we do not exclude the possibility of complications over a longer period of time, we recommend the use of plasma expanders until their impact on morbidity and mortality in the long term is well established. The best time to infuse them is about 6 h after the procedure.     

Spontaneous bacterial peritonitis and bacterascites prevalence in asymptomatic cirrhotic outpatients undergoing large-volume paracentesis

Background and Aim: Spontaneous bacterial peritonitis and bacterascites prevalence in asymptomatic cirrhotic patients on large‐volume paracentesis is unknown. The aim of this study was to investigate spontaneous bacterial peritonitis and bacterascites prevalence in a prospective cohort of cirrhotic outpatients following large‐volume paracentesis with low risk of infection. Methods: We prospectively studied all large‐volume paracenteses performed in cirrhotic outpatients for 1 year. Patients with fever, abdominal pain, peritonism or hepatic encephalopathy were excluded from the study. The ascitic fluid was analyzed by means of a reagent strip with a colorimetric scale from 0 to 4. A strip test of 0 or 1 was considered negative. In those cases with a reagent strip ≥2, conventional polymorphonuclear count was performed. Ascitic fluid culture was done into blood culture bottles in all cases. Results: We performed 204 paracenteses in 40 patients. Nine cases were excluded. Culture‐negative neutrocytic ascites was diagnosed in one case (0.5%), while bacterascites was diagnosed in six out of 195 cases (3%), mainly by gram‐positive cocci. Conclusion: The spontaneous bacterial peritonitis prevalence in outpatient cirrhotics with low risk of infection undergoing large‐volume paracentesis is very low. Moreover, the prevalence of bacterascites is low and without clinical consequences. The routine analysis of ascitic fluid may be unnecessary in this clinical setting. Nevertheless, the use of reagent strips is a reasonable alternative due to its accessibility and low cost.