Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Albumin was best for preventing postparacentesis circulatory dysfunction in cirrhosis

ACP J Club. 1997 May-Jun;126:69. doi:10.7326/ACPJC-1997-126-3-069


Source Citation

Ginès A, Fernández-Esparrach G, Monescillo A, et al. Randomized trial comparing albumin, dextran 70, and polygeline in cirrhotic patients with ascites treated by paracentesis. Gastroenterology. 1996 Oct;111:1002-10.


Abstract

Objective

To evaluate the efficacy of 3 plasma expanders in preventing postparacentesis circulatory dysfunction in patients with cirrhosis and tense ascites.

Design

Randomized controlled trial with a mean follow-up of 6 months.

Setting

12 hospitals in Spain, Italy, and Argentina.

Patients

289 patients (mean age 58 y, 69% men) with cirrhosis who were admitted with tense ascites. Exclusion criteria were serum bilirubin level > 10 mg/dL; prothrombin time < 40%; platelet count < 40 000/mm3; serum creatinine level > 3 mg/dL; gastrointestinal hemorrhage within the previous month; hepatocellular carcinoma; use of propranolol for prophylaxis of variceal bleeding; or respiratory, cardiac, or renal disease.

Intervention

Patients were assigned to total paracentesis (complete removal of ascites in a single tap) and intravenous albumin (8 g/L of ascitic fluid removed, with 50% of the dose in the first 2 h and 50% 6 to 8 h after paracentesis, 20% albumin solution, n = 97); total paracentesis and intravenous dextran 70 (8 g/L of ascitic fluid removed using the same schedule as for albumin, 6 g of dextran 70/100 mL of glucose solution, n = 93); or total paracentesis and intravenous polygeline (8 g/L of ascitic fluid removed using the same schedule as for albumin, 3.5% saline solution of polygeline, n = 99).

Main outcome measures

Postparacentesis circulatory dysfunction, time to readmission, and survival.

Main results

Postparacentesis circulatory dysfunction occurred less frequently in patients who were treated with albumin (19%) than in those treated with dextran 70 (34%) or polygeline (38%) (P = 0.004 for comparison between albumin and polygeline). {This absolute risk reduction of 19% means that 6 patients would need to be treated with albumin (rather than polygeline) to prevent 1 additional patient from developing postparacentesis circulatory dysfunction, 95% CI 3 to 15; the relative risk reduction was 51%, CI 21% to 70%.}* Postparacentesis circulatory dysfunction was associated with a shorter time to first readmission (P = 0.03) and shorter survival (P = 0.01).

Conclusion

Albumin was more effective than dextran 70 or polygeline in preventing postparacentesis circulatory dysfunction in patients with cirrhosis and tense ascites.

Sources of funding: Fondo de Investigaciones Sanitarias and Hoechst Ibérica.

For article reprint: Dr. V. Arroyo, Liver Unit, Hospital Clínic i Provincial, Villarroel 170, 08036 Barcelona, Spain. FAX 34-3-451-5272.

*Numbers calculated from data in article.


Commentary

Ascites associated with cirrhosis can generally be managed by sodium restriction and use of diuretics. In some patients with advanced cirrhosis, tense ascites that is refractory to diuretic therapy may develop and lead to discomfort, respiratory distress, or a large umbilical hernia. Large-volume paracentesis may relieve symptoms, but its use has been limited by concerns about the development of intravascular volume depletion, renal insufficiency, hyponatremia, and deterioration in liver function (1). The risk for hemodynamic instability and complications may be diminished in patients with peripheral edema, possibly because of the mobilization of extravascular sodium and fluid (2, 3).

The use of albumin after paracentesis has been shown to expand plasma volume and prevent renal failure and hyponatremia, even with removal of 10 L of fluid (4, 5). Because albumin is expensive, other synthetic plasma expanders have been studied as substitutes for maintaining plasma volume after paracentesis (6, 7).

This study found albumin to be superior to synthetic plasma expanders in preventing circulatory dysfunction. In patients who had < 5 L of fluid removed, all agents were similar. However, in patients who had ≥ 5 L of fluid removed, albumin was superior in preventing circulatory disturbances. This difference in response may exist because albumin has a much longer half-life than do synthetic agents.

This study confirms that circulatory disturbances after large-volume paracentesis can be associated with significant morbidity and mortality. These data support the use of albumin rather than synthetic plasma expanders to maintain intravascular volume after large-volume paracentesis, particularly when > 5 L of fluid is removed.

Kris V. Kowdley, MD
University of WashingtonSeattle, Washington, USA


References

1. Rocco VK, Ware AJ. Ann Intern Med. 1986;105:573-85.

2. Pockros PJ, Reynolds TB. Gastroenterology. 1986;90:1827-33.

3. Kao HW, Rakov NE, Savage E, Reynolds TB. Hepatology. 1985;5:403-7.

4. Ginès P, Titó L, Arroyo V, et al. Gastroenterology. 1988;94:1493-502.

5. Titó L, Ginès P, Arroyo V, et al. Gastroenterology. 1990;98:146-51.

6. Salerno F, Badalamenti S, Lorenzano E, Moser P, Incerti P. Hepatology. 1991;13: 707-13.

7. Ginès P, Arroyo V. J Hepatology. 1993;17: S14-8.