Management of refractory ascites in cirrhosis: Are we out of date?

Table 1 Studies evaluating large-volume paracentesis with albumin infusion and diuretic therapy in hospitalized patients with cirrhosis and refractory ascites

Ref.	Study design	Results	Conclusions/comments
Quintero et al[9], 1985	Total n: 72 Group 1: LVP and albumin - n of 38 Group 2: Diuretic therapy - n of 34	LVP with albumin had worse outcomes that diuretic therapy with adverse effects on hemodynamics, renal function, readmission, mortality	Diuretic therapy is better that LVP
Kao et al[10], 1985	Total n: 18 underwent LVP of exactly 5 L Exclusion criteria: Cardiac disease chronic renal disease active intestinal bleed encephalopathy 500 mg/d Na and 1 L/d fluid restriction Diuretic discontinued 3 d prior	No untoward effects LVP of 5 L No symptomatic hypotension or hyponatremia No worsening or acute renal failure No encephalopathy Improved pitting edema	LVP is safe in patients with peripheral edema due to mobilization of fluid to intravascular space
Salerno et al[11], 1987	Total n: 41 patients randomized into 2 groups Group A: Paracentesis + IV albumin: 20 patients Group B: Paracentesis + diuretics: 21 patients Exclusion criteria: Urinary sodium excretion rate > 20 mEq/d on a sodium-restricted diet and without diuretics Presence of cancer, encephalopathy, active gastrointestinal bleeding, renal failure, diabetes, infection, or primary cardiac disorders Hemoglobin < 9 g/dL Total bilirubin > 6 mg/dL Aminotransferases > 200 U/L Serum urea > 60 mg/dL Serum creatinine > 1.5 mg/dL	Deaths: Group A: 2/20 Group B: 3/21 Complications (encephalopathy, renal failure, and gastrointestinal bleeding): Group A: 3/20 patients Group B: 4/21 patients Group A: Satisfactory mobilization for ascites for 19/20 patients 4/20 patients did not reaccumulate ascites while 15/20 patients did reaccumulate ascites Group B: Resolution of ascites in 19/21 patients Diuretic treatment was unsuccessful for 2/21 Group B patients who were receiving the highest doses of diuretic therapy Group A: Mean body weight significantly reduced at all times after paracentesis, slight decrease in heart rate and urine osmolality (day 10). Increase noted in PAC (days 5 and 10) and urine flow rates (days 5, 10, and 15). Increased urine flow rates in 14 patients who also had significantly lower baseline urine excretions than the other 5 responsive Group A patients In the 19/21 responsive Group B patients, significant body weight reductions observed on days 10 and 15. Mean blood pressure and heart rate did not change. Significant increases noted in urine flow rate, sodium and potassium excretion, plasma albumin and potassium concentrations. Significant decrease in urine osmolality	LVP is faster and equally effective alternative to diuretic therapy and suggested that LVP might be used to decrease hospital length of stay without additional risk
Ginès et al[12], 1988	105 patients randomized into 2 groups Group A: Paracentesis + IV albumin: 52 patients Group B: paracentesis without fluid replacement: 53 patients Exclusion criteria: Similar to study by Salerno[10]	Died in hospital: Group A: 2/52 Group B: 2/53 Deaths at 1 yr: Group A: 20/52 Group B: 16/53	These findings indicated that, aside from systemic hemodynamics, there are likely multiple factors, such as renal production of vasodilators or ADH antagonists, which contribute to the development of renal failure
		Complications of hyponatremia, renal impairment, encephalopathy, gastrointestinal hemorrhage, and severe infection: Group A 9/52 Group B 16/53 Group A: Significant increase in serum albumin, GFR, free water clearance
		Group B: No change in serum albumin, significant increase in BUN, PRA, PAC, significant decrease in serum sodium
		PRA significant increase at 48 h and 5 d post LVP Group B 23/24 and 9/24 respectively Group A had none Readmission: Group A 29/52 Group B 36/53 Renal impairment: Group A: None Group B: 11/53
Ginès et al[5], 1996	289 patients randomized into 3 groups Group A: Paracentesis + IV albumin: 97 patients Group B: Paracentesis + Dextran 70: 93 patients Group C: Paracentesis + Polygeline: 99 patients Exclusion criteria: Similar to study by Salerno[10]	Deaths: Group A 2/97 Group B 4/93 Group C 6/99 PICD (based on 280 patients who developed dysfunction and had PRA measured at baseline and 6 d after the procedure): Total 85/289 Group A 17/892 Group B 31/90 Group C 37/98 PRA > 50% increase (at 2 d after LVP) if PICD occurred: 47/85 PICD associated with shorter survival Complications of hyponatremia, renal impairment, hepatic encephalopathy, gastrointestinal bleeding, bacterial infection Group A: 28/97 patients, 30 complications Group B: 28/93 patients, 43 complications Group C: 30/99 patients, 39 complications Incidence of death with PICD: 5/85 Incidence of death without PICD: 6/195	PICD found to not be spontaneously reversible and persists during follow-up PICD associated with faster reaccumulation of ascites and impaired prognosis The authors suggest that albumin is more effective than dextran 70 or polygeline at preventing postparacentesis circulatory dysfunction and is the volume expander of choice for cirrhotics who undergo paracentesis with > 5 L of ascites removed The authors discussed the pathophysiology of PICD, theorizing that PICD was most likely secondary to variable changes in neurohormonal responses, which accelerate the disease and lead to decreased long-term survival. They felt that PICD was unlikely due to a more advanced disease state, as patients with and without PICD did not differ in their degree of liver, renal, or hemodynamic function after paracentesis

LVP: Large-volume paracentesis; IV: Intravenous; PICD: Paracentesis induced circulatory dysfunction; ADH: Antidiuretic hormone.