Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis

Insufficient evidence of benefit regarding mortality due to albumin substitution in HCC-free cirrhotic patients undergoing large volume paracentesis

BACKGROUND

Current guidelines for clinical practice recommend the infusion of human albumin after large volume paracentesis. After inspecting the current evidence behind this recommendation, we decided to conduct a systematic review and meta-analysis in order to address the effect of albumin on mortality and morbidity in the context of large volume paracentesis.

METHODS

We performed a comprehensive search of large databases and abstract books of conference proceedings up to March 15th 2016 for randomized controlled trials, testing the infusion of human albumin against alternatives (vs no treatment, vs plasma expanders; vs vasoconstrictors) in HCC-free patients suffering from cirrhosis. We analyzed these trials with regard to mortality, changes in plasma renin activity (PRA), hyponatremia, renal impairment, recurrence of ascites with consequential re-admission into hospital and additional complications. We employed trial sequential analysis in order to calculate the number of patients required in controlled trials to be able to determine a statistically significant advantage of the administration of one agent over another with regard to mortality.

RESULTS

We were able to include 21 trials totaling 1277 patients. While the administration of albumin prevents a rise in PRA as well as hyponatremia, no improvement in strong clinical endpoints such as mortality could be demonstrated. Trial sequential analysis showed that at least 1550 additional patients need to be recruited into RCTs and analyzed with regard to this question in order to detect or disprove a 25% mortality effect.

CONCLUSIONS

There is insufficient evidence that the infusion of albumin after LVP significantly lowers mortality in HCC-free patients with advanced liver disease.

Management of renal failure in end-stage liver disease: A critical appraisal

Renal failure is a late consequence of end-stage liver disease (ESLD). Even with liver transplantation, pretransplant renal impairment remains a strong predictor of posttransplant mortality. This review seeks to summarize and critically appraise common therapies used in this setting, including pharmacologic agents, procedures (transjugular intrahepatic portosystemic shunt, renal replacement therapy), and simultaneous liver-kidney transplantation. More experimental extracorporal modalities, eg, albumin dialysis or bioartificial livers, will not be discussed. A brief discussion on the definition and pathophysiologic underpinnings of renal failure in ESLD will be held at the beginning to lay the groundwork for the main section. Liver Transplantation 22 1710-1719 2016 AASLD.

Risk factors of postoperative ascites on hepatic resection for hepatocellular carcinoma

Backgrounds/Aims

The aim of this study was to identify the risk factors of the development of large amounts of ascites (LA) after hepatic resection for hepatocellular carcinoma (HCC).

Methods

The medical records of 137 consecutive patients who underwent hepatic resection for HCC from January 2010 to December 2014 were retrospectively reviewed. Patients were divided into two groups: LA group, with ascites drainage >500 cc per day over 3 days (n=37) and control group (n=100). Preoperative and intraoperative clinical variables were compared between the two groups.

Results

Thirty-seven (27.0%) patients developed LA. Platelet counts of <100,000/mm³, ICG-R15 >10%, CTP scores of 6 or 7 points, major resection, the presence of cirrhosis, preoperative ascites, and portal hypertension were significantly more frequent in LA group. Multivariate analysis revealed that a higher CTP score (HR=4.1), the presence of portal hypertension (HR=26.7), and major resection (HR=18.5) were independent and significant risk factors of postoperative ascites development. Persistent refractory ascites developed in 6 (16.2%) patients who succumbed to hepatic failure during follow-up.

Conclusions

Patients with a 6 or 7 point CTP score, major hepatic resection and/or portal hypertension were more likely to develop LA and experience deterioration of liver function after surgery. The selection of patients for hepatic resection should be based on a balanced assessment of the benefits of HCC treatment and risk of postoperative liver failure.

AISF-SIMTI position paper: the appropriate use of albumin in patients with liver cirrhosis

The use of human albumin is common in hepatology since international scientific societies support its administration to treat or prevent severe complications of cirrhosis, such as the prevention of post-paracentesis circulatory dysfunction after large-volume paracentesis and renal failure induced by spontaneous bacterial peritonitis, and the treatment of hepatorenal syndrome in association with vasoconstrictors. However, these indications are often disregarded, mainly because the high cost of human albumin leads health authorities and hospital administrations to restrict its use. On the other hand, physicians often prescribe human albumin in patients with advanced cirrhosis for indications that are not supported by solid scientific evidence and/or are still under investigation in clinical trials.In order to implement appropriate prescription of human albumin and to avoid its futile use, the Italian Association for the Study of the Liver (AISF) and the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) nominated a panel of experts, who reviewed the available clinical literature and produced practical clinical recommendations for the use of human albumin in patients with cirrhosis.

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

Cirrhosis is a major cause of morbidity and mortality worldwide with liver transplantations as it only possible cure. In the face of a significant organ shortage many patients die waiting. A major complication of cirrhosis is the development of portal hypertension and ascites. The management of ascites has barely evolved over the last hundred years and includes only a few milestones in our treatment approach, but has overall significantly improved patient morbidity and survival. Our mainstay to ascites management includes changes in diet, diuretics, shunt procedures, and large volume paracentesis. The understanding of the pathophysiology of cirrhosis and portal hypertension has significantly improved in the last couple of decades but the changes in ascites management have not seemed to mirror this newer knowledge. We herein review the history of ascites management and discuss some its current limitations.

Albumin May Prevent the Morbidity of Paracentesis-Induced Circulatory Dysfunction in Cirrhosis and Refractory Ascites: A Pilot Study

BACKGROUND

Large-volume total paracentesis may result in paracentesis-induced circulatory dysfunction, which is associated with poor outcomes.

AIMS

To explore the short- and long-term effects of paracentesis-induced circulatory dysfunction on systemic hemodynamics, renal function and other cirrhosis-related complications in patients with refractory ascites, following subtotal large-volume paracentesis.

METHODS

Patients with cirrhosis and refractory ascites without renal dysfunction had systemic hemodynamics, renal function, and neurohormones (plasma active renin, aldosterone, norepinephrine and angiotensin II) measured pre- and 6 days post-paracentesis. Paracentesis was limited to ≤8 L with 6-8 g of albumin per liter ascites drained. Patients were followed up until transjugular intrahepatic portosystemic shunt insertion, liver transplantation, or death. Paracentesis-induced circulatory dysfunction was defined as >50 % increase in plasma active renin 6 days post-paracentesis.

RESULTS

Fifty-seven patients (mean age 59.0 ± 9.4 years) had mean 6.8 ± 1.8 L of ascites removed with 9 ± 3 g of albumin given/L of ascites drained. Patients were followed up for 715 ± 104 days. Twenty-three patients (40.4 %) developed paracentesis-induced circulatory dysfunction with unchanged serum creatinine on day six, despite worsening of hemodynamics (mean arterial pressure 90 ± 10 mmHg at baseline vs. 84 ± 8 mmHg on day six, p < 0.05). Similar hemodynamic changes were observed among patients without paracentesis-induced circulatory dysfunction. There was no significant difference in the long-term renal function or cirrhosis-related complications between the groups.

CONCLUSION

The occurrence of paracentesis-induced circulatory dysfunction, as defined by plasma active renin, may not have a significant short- and long-term impact on renal function or cirrhosis-related complications in patients with refractory ascites who undergo subtotal paracentesis with albumin infusion.

Management of ascites in children

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. There are many causes of fetal, neonatal and pediatric ascites; however, chronic liver disease and subsequent cirrhosis remain the most common. The medical and surgical management of ascites in children is dependent on targeting the underlying etiology. Broad categories of management strategies include: sodium restriction, diuresis, paracentesis, intravenous albumin, prevention and treatment of infection, surgical and endovascular shunts and liver transplantation. This review updates and expands the discussion of the unique considerations regarding the management of cirrhotic and non-cirrhotic ascites in the pediatric patient.

Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin - Revised

Chapter 5 'Human Albumin' that was suspended on January 10, 2011 has been completed and updated in the present version.

The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations

Several pathogenic processes have been implicated in the development of abdominal ascites. Portal hypertension, most usually in the context of liver cirrhosis, can explain about 75% of the cases, whereas infective, inflammatory and infiltrative aetiologies can account for the rest. In this article, we discuss the consensus best practice as published by three professional bodies for the management of ascites, spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). The aim of this study was to compare available clinical guidelines and identify areas of agreement and conflict. We carried out a review of the guidance documentation published by three expert bodies including the British Society of Gastroenterology, the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD), as well as a wider literature search for ascites, SBP and HRS. Abdominal ultrasonography, diagnostic paracentesis and ascitic fluid cultures are recommended by all three guidelines, especially when there is strong clinical suspicion for infection. EASL and AASLD advocate the use of ascitic amylase and mycobacterial cultures/PCR when there is strong suspicion for tuberculosis and pancreatitis, respectively. Ascitic cytology can be useful when cancer is suspected and has a good diagnostic yield if performed correctly. EASL supports the use of urinary electrolytes for all patients; however, the British Society of Gastroenterology and AASLD only recommend their use for therapy monitoring. All three societies recommend cefotaxime as the antibiotic of choice for SBP and large-volume paracentesis for the management of ascites greater than 5 l in volume. For HRS, cautious diuresis, volume expansion with albumin and the use of vasoactive drugs are recommended. There appears to be good concordance between recommendations by the European, American and British guidelines for the management of ascites and the possible complications arising from it.

Abdominal Circulatory Interactions

The abdominal compartment is separated from the thoracic compartment by the diaphragm. Under normal circumstances, a large portion of the venous return crosses the splanchnic and nonsplanchnic abdominal regions before entering the thorax and the right side of the heart. Mechanical ventilation may affect abdominal venous return independent of its interactions at the thoracic level. Changes in pressure in the intra-abdominal compartment may have important implications for organ function within the thorax, particularly if there is a sustained rise in intra-abdominal pressure. It is important to understand the consequences of abdominal pressure changes on respiratory and circulatory physiology. This article elucidates important abdominal-respiratory-circulatory interactions and their clinical effects.

Are all fluids bad for the kidney?

PURPOSE OF REVIEW

To describe the harmful effects of intravenous fluids on kidney structure and function and summarize recent comparisons between different fluids and their effect on kidney outcome.

RECENT FINDINGS

Administration of intravenous fluids may contribute to the development and sustention of acute kidney injury. In excess, fluids cause kidney interstitial edema and venous congestion, which prevents renal blood flow and glomerular filtration rate. In contrast to balanced crystalloids, chloride-rich solutions impair renal blood flow via autoregulatory mechanisms. Synthetic colloids, such as hydroxyethyl starches, gelatins, and dextrans are potentially nephrotoxic because they can cause osmotic nephrosis, which, in susceptible patients, might precede permanent kidney damage. Albumin solutions appear well tolerated to use in septic patients, although their renal efficacy over balanced crystalloids is not established. In contrast, administration of albumin solutions to patients with decompensated liver failure effectively prevents and ameliorates hepatorenal syndrome.

SUMMARY

Being nephrotoxic, synthetic colloids should be avoided in patients with reduced renal reserve, such as in critically ill patients and in patients with preexisting renal dysfunction. Suggested adverse effects with chloride-rich solutions need confirmation from ongoing trials. Albumin solutions are well tolerated in patients with sepsis and/or liver failure and improve outcomes in the latter.

Hepatic Failure

The progression of liver disease can cause several physiologic derangements that may precipitate hepatic failure and require admission to an intensive care unit. The underlying pathology may be acute, acute-on chronic, or chronic in nature. Liver failure may manifest with a variety of clinical signs and symptoms that need prompt attention. The compromised synthetic and metabolic activity of the failing liver affects all organ systems, from neurologic to integumentary. Supportive care and specific therapies should be instituted in order to improve outcome and minimize time of recovery.

In this chapter we will discuss the definition, clinical manifestations, workup, and management of acute and chronic liver failure and the general principles of treatment of these patients. Management of liver failure secondary to certain common etiologies will also be presented. Finally, liver transplantation and alternative therapies will also be discussed.

AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis

The use of human albumin is common in hepatology since international scientific societies support its administration to treat or prevent severe complications of cirrhosis, such as the prevention of post-paracentesis circulatory dysfunction after large-volume paracentesis and renal failure induced by spontaneous bacterial peritonitis, and the treatment of hepatorenal syndrome in association with vasoconstrictors. However, these indications are often disregarded, mainly because the high cost of human albumin leads health authorities and hospital administrations to restrict its use. On the other hand, physicians often prescribe human albumin in patients with advanced cirrhosis for indications that are not supported by solid scientific evidence and/or are still under investigation in clinical trials. In order to implement appropriate prescription of human albumin and to avoid its futile use, the Italian Association for the Study of the Liver (AISF) and the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) nominated a panel of experts, who reviewed the available clinical literature and produced practical clinical recommendations for the use of human albumin in patients with cirrhosis.

Role of albumin in diseases associated with severe systemic inflammation: Pathophysiologic and clinical evidence in sepsis and in decompensated cirrhosis

The metabolism of albumin in inflammatory states such as sepsis or major surgery is complex and still not well characterized. Nevertheless, in inflammatory states, albumin synthesis has been observed to increase. By contrast, in decompensated cirrhosis, a disease characterized by systemic inflammation, albumin synthesis by the liver may decrease to 30% to 50% of normal values. Furthermore, in these conditions, there are high capillary leakage and altered albumin kinetics. The discussion regarding the effect of exogenous albumin administration on intravascular volume in inflammatory states should therefore address albumin turnover. To add complexity to our understanding of the effects of albumin, there are many data indicating that the therapeutic action of albumin is mediated not only through the impact on plasma volume expansion but also through a modulatory effect on inflammation and oxidative stress. All these characteristics are relevant to diseases associated with systemic inflammation including sepsis and decompensated cirrhosis.

Safety, complications and outcome of large volume paracentesis with or without albumin therapy in children with severe ascites due to liver disease

BACKGROUND & AIMS

There are currently no published data on post-paracentesis circulatory dysfunction (PPCD) or its prevention in children. Our study was aimed to analyze the safety and complications of large volume paracentesis (LVP) in children with severe ascites due to chronic liver disease with or without albumin therapy.

METHODS

A prospective longitudinal observational study enrolled children with severe ascites who underwent single time LVP at admission. They were divided into albumin infused (AI) and albumin non-infused (ANI) groups. Hemodynamic monitoring and laboratory parameters including plasma renin activity (PRA) were compared between baseline, 48 h and day 6 of LVP. Their outcome at 3 months and maximal follow-up were noted.

RESULTS

32 children (AI, n=17; ANI, n=15) had comparable baseline characteristics and 90.6% had high PRA at onset. The incidence of PPCD was 37.5% (ANI: 67%; AI: 12%, p=0.003), occurred if ascitic fluid extraction was >197.5 ml/kg (sensitivity: 90%; specificity: 50%, p=0.01) and if flow rate was higher in ANI group (1224 ± 476 vs. 678 ± 214 ml/h, p=0.009). ANI patients were susceptible to asymptomatic, persistent hyponatremia (baseline vs. day 6, 131 ± 4 vs. 128 ± 6 mEq/L; p=0.04) and had higher rates of recurrent ascites (42%) and hospital readmission (67%) within 3 months. No survival benefit among the AI or non-PPCD groups was demonstrated.

CONCLUSIONS

LVP is safe in all age groups, best performed under albumin cover to overcome the problems of PPCD and hyponatremia. It is prudent to restrict volume extraction to less than 200 ml/kg actual dry weight for all and flow rate of 680 ml/h in ANI.

Therapeutic effects of short- and intermediate-term tolvaptan administration for refractory ascites in patients with advanced liver cirrhosis

AIM

Tolvaptan, an oral arginine vasopressin V2 receptor antagonist, became available for hepatic ascites. We evaluated the therapeutic efficacy and safety of tolvaptan administration to treat refractory ascites.

METHODS

Data were collected from 15 hospitalized patients with cirrhosis (hepatitis C, 10; alcoholism, five) after adding tolvaptan (3.75-11.25 mg/day) to conventional diuretics. Bodyweights and serum sodium and creatinine concentrations were measured. Tolvaptan was continued for 4 weeks or longer for a median follow-up period of 42 days (range, 28-56).

RESULTS

In the first week (introduction phase), tolvaptan significantly reduced median weight (66.6, 65.9 and 63.1 kg on days 0, 1 and 7, respectively; P < 0.004). The numbers of good responders (≥3 kg reduction in 4 days), responders (<3 kg weight reduction) and non-responders (no weight reduction) were seven (46.7%), six (40.0%) and two of the 15 (13.3%), respectively. The two non-responders had concomitant chylous pleural effusion or spontaneous bacterial peritonitis. All patients continued tolvaptan for 2 weeks or longer and six (40%, three good responders and three responders) were treated for a median of 42 days without additional intervention. During this intermediate-term administration of tolvaptan, the median weight reduction was statistically significant (65.4, 61.9 and 56.9 kg on days 0, 7 and 42, respectively; P < 0.030) and there was no serum sodium imbalance or renal dysfunction; but two of these six developed hepatic coma.

CONCLUSION

Tolvaptan safely alleviated fluid retention caused by hepatic cirrhosis. Intermediate-term administration of tolvaptan apparently helped maintain weight reduction achieved during the introduction phase.

[Supportive care for malignant ascites in palliative phase: Place of paracentesis and diuretics]

Malignant ascites, occurring in advanced stages of cancer, is linked with poor prognosis and can cause invalidating symptoms. Physiopathological mechanisms of ascites formation are complex and have yet to be fully elucidated. In most cases, ascites is due to peritoneal carcinomatosis in which vascular permeability is enhanced by VEGF production while lymphatic drainage decreases. Ascites can also be secondary to portal hypertension, for example in case of multiple liver metastases, or due to lymphatic obstruction. While paracentesis and diuretics are commonly used, their efficiency has never been compared in a randomized controlled study. Paracentesis brings immediate but temporary relief in over 90% of cases, and implies multiple hospitalizations. Literature reports ascites control by aldosterone alone or in association with furosemide. But, available data is controversial, and there is no predictive factor to identify patients that respond to diuretic treatment. The indication of diuretic treatment is left to the appreciation of physicians. Existing recommendations are old, and practices influenced by results obtained in non-neoplastic ascites. Additional evidences are required before guidelines can be established for the palliative management of malignant ascites.

Key Controversies in Colloid and Crystalloid Fluid Utilization

Nearly 2 centuries have passed since the use of intravenous fluid became a foundational component of clinical practice. Despite a steady stream of published investigations on the topic, questions surrounding the choice, dose, timing, targets, and cost-effectiveness of various fluid options remain insufficiently answered. In recent years, 2 of the most debated topics reference the role of albumin in acute care and the safety of normal saline. Although albumin has a place in therapy for specific patient populations, its high cost relative to other fluids makes it a less desirable option for hospitals and health systems with escalating formulary scrutiny. Pharmacists bear responsibility for reconciling this disparity and supporting the rational use of albumin in acute care through a careful evaluation of recently published literature. In parallel, it has become clear that crystalloids should no longer be considered a homogenous class of fluids. The past reliance on normal saline has been questioned due to recent findings of renal dysfunction attributable to the solution's supraphysiologic chloride concentration. These safety concerns with 0.9% sodium chloride may result in a practice shift toward more routine use of "balanced crystalloids," such as lactated Ringer's or Plasma-Lyte, that mimic the composition of extracellular fluid. The purpose of this review is to summarize the evidence regarding these 2 important fluid controversies that are likely to affect hospital pharmacists in the coming decades - the evidence-based use of human albumin and the rising role of balanced salt solutions in clinical practice.

Clinical Profile and Complications of Paracentesis in Refractory Ascites Patients With Cirrhosis

BACKGROUND

Large volume paracentesis is found to be safer and more effective for the treatment of tense ascites compared with larger-than-usual doses of diuretics according to studies. The objectives of the study was to evaluate patients with refractory ascites regarding clinical profile, technique of paracentesis, complications, amount of ascites drained, prognosis and co-morbid conditions associated with it.

METHODS

Retrospective study was performed including patients between January 2011 and December 2013 with data pooled from total of five hospitals. A total of 4,389 paracenteses were performed on the 1,218 patients with a mean volume of 4,900 ± 2,795 mL ascitic fluid drained. Blind technique, ultrasound-guided technique of paracentesis and pig tail catheter drainage were evaluated. Diabetes mellitus data from available patients and data regarding co-morbidities were analyzed. Coagulation abnormalities in patients were studied.

RESULTS

Study group age ranged from 34 to 79 years, and alcohol is the main cause of cirrhosis. Dyslipidemia was observed in 1,080 patients (88.66%). At the time of inclusion in the study, 40% of the patients had ≥ 2 other cirrhosis-related complications and 20% of the study population had ≥ 3 complications. Early complications occurred in 27.5% (337) of patients and late complications constituted 16.83% (205 patients).

CONCLUSIONS

Even with abnormal coagulation, paracentesis is a safe procedure. But significant co-morbidities should be addressed with care in cirrhosis patients. Ultrasound guidance during the procedure whenever required should be encouraged.

Low dose albumin for the prevention of renal impairment following large volume paracentesis in cirrhosis

OBJECTIVES

To evaluate the effect of low dose Albumin i.e. 4 grams per litre of ascitic fluid after large volume paracentesis (LVP) for the prevention of paracentesis induced circulatory dysfunction (PICD) related renal impairment in cirrhosis.

METHODS

Case records of all patients with cirrhosis who underwent LVP from January 12(th), 2011 till December 29(th), 2013 were reviewed. Patients were excluded if they had spontaneous bacterial peritonitis, creatinine >1.5 mg/dl, hepatoma or if volume of ascitic fluid removed was <5 litres. Data including age, gender, cause of cirrhosis, CTP score and volume of ascitic fluid drained were noted. In addition serum creatinine and serum sodium at baseline and one week post paracentesis were recorded.

RESULTS

Two hundred and fourteen patients with cirrhosis underwent LVP during the study period. One hundred and thirty nine patients met the inclusion criteria and were analyzed. Patients were divided into two groups based on the amount of albumin given. The amount of albumin given was 25 grams and 50 grams while the volume of ascitic fluid removed were 6.2±1 litres and 10.4±1.5 litres in groups A and B respectively. One hundred and eight patients were in group A while thirty one patients were in group B respectively. Both groups received albumin at a dose of 4 grams per litre of ascitic fluid removed. Mean age in both groups were 53 years. Hepatitis C was the commonest etiology in both the groups, followed by Hepatitis B. More than 70% patients in both the groups were in child class C. Serum creatinine at baseline and one week post LVP was 1.04±0.24 mg/dl and 1.07±0.35 mg/dl in GROUP A while 1.11±0.23 mg/dl and 1.41±0.94 mg/dl in GROUP B. (P value 0.35). Similarly, serum sodium at baseline and one week post LVP was 130 ±5.6 meq/lit and 129.6±5.9 meq/lit in GROUP A while 127.6±5.8 meq/lit and 128±6.2 meq/lit in GROUP B respectively. (P value 0.14).

CONCLUSION

This study suggests that 4 grams of albumin per litre of ascitic fluid drained is effective in preventing the PICD related renal impairment following large volume paracentesis in cirrhosis.

Management of cirrhotic ascites

The most common complication to chronic liver failure is ascites. The formation of ascites in the cirrhotic patient is caused by a complex chain of pathophysiological events involving portal hypertension and progressive vascular dysfunction. Since ascites formation represents a hallmark in the natural history of chronic liver failure it predicts a poor outcome with a 50% mortality rate within 3 years. Patients with ascites are at high risk of developing complications such as spontaneous bacterial peritonitis, hyponatremia and progressive renal impairment. Adequate management of cirrhotic ascites and its complications betters quality of life and increases survival. This paper summarizes the pathophysiology behind cirrhotic ascites and the diagnostic approaches, as well as outlining the current treatment options. Despite improved medical treatment of ascites, liver transplantation remains the ultimate treatment and early referral of the patient to a highly specialized hepatology unit should always be considered.

Immunomodulatory and antioxidant function of albumin stabilises the endothelium and improves survival in a rodent model of chronic liver failure

BACKGROUND & AIMS

Liver failure is characterized by endothelial dysfunction, which results in hemodynamic disturbances leading to renal failure. Albumin infusion improves hemodynamics and prevents renal dysfunction in advance liver failure. These effects are only partly explained by the oncotic properties of albumin. This study was designed to test the hypothesis that albumin exerts its beneficial effects by stabilising endothelial function.

METHODS

In vivo: systemic hemodynamics, renal function, markers of endothelial dysfunction (ADMA) and inflammation were studied in analbuminaemic and Sprague-Dawley rats, 6-weeks after sham/bile duct ligation surgery. In vitro: human umbilical vein endothelial cells were stimulated with LPS with or without albumin. We studied protein expression and gene expression of adhesion molecules, intracellular reactive oxygen species, and cell stress markers.

RESULTS

Compared to controls, analbuminaemic rats had significantly greater hemodynamic deterioration after bile duct ligation, resulting in worse renal function and shorter survival. This was associated with significantly greater plasma renin activity, worse endothelial function, and disturbed inflammatory response. In vitro studies showed that albumin was actively taken up by endothelial cells. Incubation of albumin pre-treated endothelial cells with LPS was associated with significantly less activation compared with untreated cells, decreased intracellular reactive oxygen species, and markers of cell stress.

CONCLUSIONS

These results show, for the first time, that absence of albumin is characterised by worse systemic hemodynamics, renal function and higher mortality in a rodent model of chronic liver failure and illustrates the important non-oncotic properties of albumin in protecting against endothelial dysfunction.

Managing complications in cirrhotic patients

Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.

Hepatorenal syndrome: aetiology, diagnosis, and treatment

Acute renal impairment is common in patients with chronic liver disease, occurring in approximately 19% of hospitalised patients with cirrhosis. A variety of types of renal impairment are recognised. The most important of these is the hepatorenal syndrome, a functional renal impairment due to circulatory and neurohormonal abnormalities that underpin cirrhosis. It is one of the most severe complications of cirrhosis with survival often measured in weeks to months. A variety of treatment options exist with early diagnosis and appropriate treatment providing the best hope for cure. This paper provides a comprehensive and up-to-date review of hepatorenal syndrome and lays out the topic according to the following sections: pathophysiology, historical developments, diagnostic criteria and limitations, epidemiology, precipitating factors, predictors, clinical and laboratory findings, prognosis, treatment options, prophylaxis, and conclusion.

Role of human albumin in the management of complications of liver cirrhosis

Albumin is a negatively charged, relatively small protein synthesized by liver cells. Is the most abundant protein in extracellular fluid and accounts for about 70% of the plasma colloid osmotic pressure. Therefore it plays a crucial role in regulating fluid distribution in the body. In addition, albumin possesses functional domains with important non-oncotic properties, such as potent anti-oxydant and scavenging activities, binding of highly toxic reactive metal species and a great amount of endogenous and exogenous substances. We have recently learned that albumin in cirrhosis undergoes a number of post-transcriptional changes that greatly impair its non-oncotic properties. The overall assessment of these changes clearly shows that the relative abundance of the native form of albumin is significantly reduced in hospitalized patients with cirrhosis and that these abnormalities worsen in parallel with the increasing severity of the disease. Thus, it is time to abandon the concept of serum albumin concentration and refer to the effective albumin concentration, that is the native intact albumin. Given the pathophysiological context in which we use human albumin in patients with cirrhosis, who are characterized by peripheral vasodilation and a low-grade but sustained inflammatory state, the use of albumin in patients with cirrhosis should aim at enhancing effective hypovolemia and exploiting its antioxidant and scavenging activities. The indications for the use of albumin in cirrhosis that clearly emerge from evidence-based medicine are represented by conditions characterized by an acute aggravation of effective hypovolemia and inflammation, such as such post-paracentesis circulatory dysfunction, spontaneous bacterial peritonitis, and hepatorenal syndrome. Other indications to the use of albumin that still require further studies are represented by bacterial infections other than spontaneous bacterial peritonitis, hepatic encephalopathy and long-term treatment of ascites, which has been debated for the last half-century.

Albumin administration is associated with acute kidney injury in cardiac surgery: a propensity score analysis

Introduction

The risk of acute kidney injury (AKI) with the use of albumin-containing fluids compared to starches in the surgical intensive care setting remains uncertain. We evaluated the adjusted risk of AKI associated with colloids following cardiac surgery.

Methods

We performed a retrospective cohort study of patients undergoing on-pump cardiac surgery in a tertiary care center from 2008 to 2010. We assessed crystalloid and colloid administration until 36 hours after surgery. AKI was defined by the RIFLE (risk, injury, failure, loss and end-stage kidney disease) risk and Acute Kidney Injury Network (AKIN) stage 1 serum creatinine criterion within 96 hours after surgery.

Results

Our cohort included 984 patients with a baseline glomerular filtration rate of 72 ± 19 ml/min/1.73 m². Twenty-three percent had a reduced left ventricular ejection fraction (LVEF), thirty-one percent were diabetics and twenty-three percent underwent heart valve surgery. The incidence of AKI was 5.3% based on RIFLE risk and 12.0% based on the AKIN criterion. AKI was associated with a reduced LVEF, diuretic use, anemia, heart valve surgery, duration of extracorporeal circulation, hemodynamic instability and the use of albumin, pentastarch 10% and transfusions. There was an important dose-dependent AKI risk associated with the administration of albumin, which also paralleled a higher prevalence of concomitant risk factors for AKI. To address any indication bias, we derived a propensity score predicting the likelihood to receive albumin and matched 141 cases to 141 controls with a similar risk profile. In this analysis, albumin was associated with an increased AKI risk (RIFLE risk: 12% versus 5%, P = 0.03; AKIN stage 1: 28% versus 13%, P = 0.002). We repeated this methodology in patients without postoperative hemodynamic instability and still identified an association between the use of albumin and AKI.

Conclusions

Albumin administration was associated with a dose-dependent risk of AKI and remained significant using a propensity score methodology. Future studies should address the safety of albumin-containing fluids on kidney function in patients undergoing cardiac surgery.

Randomized, controlled pilot study comparing large-volume paracentesis using wall suction and traditional glass vacuum bottle methods

OBJECTIVES

Large-volume paracentesis (LVP) can be time and labor intensive depending on the amount of ascites removed and the method of drainage. Wall suction has been adopted as the preferred method of drainage at many centers, though the safety and benefits of this technique have not been formally evaluated. The primary objective of this study was to define the cost and time savings of wall suction over the traditional glass vacuum bottle method for ascites drainage. The secondary objective was to compare the safety profile and patient satisfaction using these two techniques.

METHODS

We conducted a randomized, controlled pilot study of the wall suction versus vacuum bottle methods for LVP in hospitalized patients. All LVPs were performed under ultrasound guidance by a single proceduralist. Patients with at least 4 liters removed received 25% intravenous albumin, 8 g/liter fluid removed. Demographic, clinical characteristics, and procedure details were recorded. Laboratory and hemodynamic data were recorded for 24 h prior to and 24-48 h post LVP. An electronic chart review was conducted to evaluate procedure-related complications. Data were compared using Fisher's exact test, t test, or Mann-Whitney U test.

RESULTS

Thirty-four patients were randomized to wall suction at 200 mmHg (n = 17) or glass vacuum bottle drainage (n = 17). Wall suction was significantly faster and less costly than vacuum bottle drainage (7 versus 15 min, p = 0.002; $4.59 versus $12.73, p < 0.001). There were no differences in outcomes at 24 and 48 h post LVP, or at 60-day follow up.

CONCLUSION

Performing LVP using wall suction resulted in significantly shorter procedure time and supply cost savings. There were no differences in outcomes between the groups, suggesting equivalent safety, though larger studies powered to detect small differences are needed. Given its efficiency, convenience, and cost effectiveness, wall suction may be a superior method of ascites drainage for LVP.

Paracentesis-induced circulatory dysfunction: a primer for the interventional radiologist

Paracentesis-induced circulatory dysfunction is a complication of large volume paracentesis that leads to faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival. Knowledge of the pathophysiology, clinical presentation, diagnosis, and prevention of this condition is vital to the interventional radiologist as a valued team member in the treatment of ascites.

Post-paracentesis circulatory derangements are related to monocyte activation

BACKGROUND & AIMS

Post-paracentesis circulatory dysfunction is associated with development of hepatorenal syndrome and increased mortality. The impact of large volume paracentesis (LVP) on the 24-h blood pressure (BP) profile is unknown, and the relationship to Na+-retentive and pro-inflammatory cytokines also remains unknown. The aims of this study were to (i) define the effects of LVP with albumin administration on 24-h BP profiles, and (ii) relate changes in BP over time to changes in Na+-retentive hormones, clinical factors and inflammatory cytokines.

METHODS

Ten patients undergoing LVP had 24-h ambulatory BP monitoring performed pre- and post-paracentesis. Markers of the innate immune system, bacterial translocation and Na+-retentive hormones were drawn pre- and post-LVP.

RESULTS

Mean arterial pressure (MAP) dropped in nine of the 10 patients in the 24 h following a paracentesis compared to 24 h preceding the procedure (mean drop of 5.5 mmHg, P<0.005). A mixed effects model was used to define time-covariate interactions in predicting changes in BP profile. Monocyte chemotactic protein-1 (MCP1) was associated with Δsystolic BP (β=-0.011, P<0.05), Δdiastolic BP (β=-0.012, P<0.05) and ΔMAP (β=-0.012, P<0.05). Plasma renin activity was also significantly associated with Δsystolic BP (β=-0.21, P<0.05). Renal function was also significantly reduced following LVP.

CONCLUSIONS

Systolic, diastolic and MAP decreased over 24 h after LVP compared to the 24 h pre-LVP. This drop is related to increases in MCP-1 after LVP. Increased MCP-1, a marker of monocyte activation, was strongly related to changes in BP.

Human serum albumin, systemic inflammation, and cirrhosis

Human serum albumin (HSA) is one of the most frequent treatments in patients with decompensated cirrhosis. Prevention of paracentesis-induced circulatory dysfunction, prevention of type-1 HRS associated with bacterial infections, and treatment of type-1 hepatorenal syndrome are the main indications. In these indications treatment with HSA is associated with improvement in survival. Albumin is a stable and very flexible molecule with a heart shape, 585 residues, and three domains of similar size, each one containing two sub-domains. Many of the physiological functions of HSA rely on its ability to bind an extremely wide range of endogenous and exogenous ligands, to increase their solubility in plasma, to transport them to specific tissues and organs, or to dispose of them when they are toxic. The chemical structure of albumin can be altered by some specific processes (oxidation, glycation) leading to rapid clearance and catabolism. An outstanding feature of HSA is its capacity to bind lipopolysaccharide and other bacterial products (lipoteichoic acid and peptidoglycan), reactive oxygen species, nitric oxide and other nitrogen reactive species, and prostaglandins. Binding to NO and prostaglandins are reversible, so they can be transferred to other molecules at different sites from their synthesis. Through these functions, HSA modulates the inflammatory reaction. Decompensated cirrhosis is a disease associated systemic inflammation, which plays an important role in the pathogenesis of organ or system dysfunction/failure. Although, the beneficial effects of HAS have been traditionally attributed to plasma volume expansion, they could also relate to its effects modulating systemic and organ inflammation.

Liver cirrhosis

Cirrhosis is an increasing cause of morbidity and mortality in more developed countries, being the 14th most common cause of death worldwide but fourth in central Europe. Increasingly, cirrhosis has been seen to be not a single disease entity, but one that can be subclassified into distinct clinical prognostic stages, with 1-year mortality ranging from 1% to 57% depending on the stage. We review the current understanding of cirrhosis as a dynamic process and outline current therapeutic options for prevention and treatment of complications of cirrhosis, on the basis of the subclassification in clinical stages. The new concept in management of patients with cirrhosis should be prevention and early intervention to stabilise disease progression and to avoid or delay clinical decompensation and the need for liver transplantation. The challenge in the 21st century is to prevent the need for liver transplantation in as many patients with cirrhosis as possible.

Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk

Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.

Review article: advances in the management of patients with cirrhosis and portal hypertension-related renal dysfunction

BACKGROUND

In cirrhosis, portal hypertension is associated with a spectrum of renal dysfunction that has significant implications for morbidity and mortality.

AIM

To discuss recent progress in the patho-physiological mechanisms and therapeutic options for portal hypertension-related renal dysfunction.

METHODS

A literature search using Pubmed was performed.

RESULTS

Portal hypertension-related renal dysfunction occurs in the setting of marked neuro-humoral and circulatory derangement. A systemic inflammatory response is a pathogenetic factor in advanced disease. Such physiological changes render the individual vulnerable to further deterioration of renal function. Patients are primed to develop acute kidney injury when exposed to additional 'hits', such as sepsis. Recent progress has been made regarding our understanding of the aetiopathogenesis. However, treatment options once hepatorenal syndrome develops are limited, and prognosis remains poor. Various strategies to prevent acute kidney injury are suggested.

CONCLUSION

Prevention of acute kidney injury in high risk patients with cirrhosis and portal hypertension-related renal dysfunction should be a clinical priority.

Monitoring and managing hepatic disease in anaesthesia

Patients with liver disease have multisystem organ dysfunction that leads to physiological perturbations ranging from hyperbilirubinaemia of no clinical consequence to severe coagulopathy and metabolic disarray. Patient-specific risk factors, clinical scoring systems, and surgical procedures stratify perioperative risk for these patients. The anaesthetic management of patients with hepatic dysfunction involves consideration of impaired drug metabolism, hyperdynamic circulation, perioperative hypoxaemia, bleeding, thrombosis, and hepatic encephalopathy.

Clinical indications for the albumin use: still a controversial issue

Human serum albumin (HSA) is the most abundant circulating protein and accounts for about 70% of the plasma colloid osmotic pressure. Beside the well known capacity to act as plasma-expander, HSA is provided of many other properties which are unrelated to the regulation of fluid compartmentalization, including binding and transport of many endogenous and exogenous substances, antioxidant function, immuno-modulation, anti-inflammatory activity, and endothelial stabilization. Treatment (hepatorenal syndrome) or prevention (renal failure after spontaneous bacterial peritonitis and post-paracentesis circulatory dysfunction after large volume paracentesis) of severe clinical complications in patients with cirrhosis and fluid resuscitation in critically ill patients, when crystalloids and non-proteic colloids are not effective or contra-indicated, represents the major evidence-based clinical indications for HSA administration. However, a large proportion of HSA prescription is inappropriate. Despite the existence of solid data against a real benefit, HSA is still given for nutritional interventions or for correcting hypoalbuminemia per se (without hypovolemia). Other clinical uses for HSA administration not supported by definitive scientific evidence are long-term treatment of ascites, nephrotic syndrome, pancreatitis, abdominal surgery, acute distress respiratory syndrome, cerebral ischemia, and enteric diseases. HSA prescription should be not uncritically restricted. Enforcement of clinical practice recommendations has been shown to allow a more liberal use for indications supported by strong scientific data and to avoid the futile administration in settings where there is a lack of clinical evidence of efficacy. As a result, a more appropriate HSA use can be achieved maintaining the health care expenditure under control.

TIPS: 25 years later

In the 25 years since the first TIPS intervention has been performed, technical standards, indications, and contraindications have been set up. The previous considerable problem of shunt failure by thrombosis or intimal proliferation in the stent or in the draining hepatic vein has been reduced considerably by the availability of polytetrafluoroethylene (PTFE)-covered stents resulting in reduced rebleeding and improved survival. Unfortunately, most clinical studies have been performed prior to the release of the covered stent and, therefore, do not represent the present state of the art. In spite of this, TIPS has gained increasing acceptance in the treatment of the various complications of portal hypertension and vascular diseases of the liver.

Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications

Since the introduction of human serum albumin as a plasma expander in the 1940s, considerable research has allowed a better understanding of its biochemical properties and potential clinical benefits. Albumin has a complex structure, which is responsible for a variety of biological functions. In disease, the albumin molecule is susceptible to modifications that may alter its biological activity. During the last decades, different methods to measure albumin function have been developed. Recent studies have shown that not only albumin concentration but also albumin function is reduced in liver failure. This observation led to the concept of effective albumin concentration, which represents the fact that plasma albumin concentration does not reflect its function. Indeed, in liver disease albumin function is several times less than its concentration. In patients with cirrhosis, albumin infusion reduces mortality in patients with spontaneous bacterial peritonitis and improves outcome following large volume paracentesis. In combination with vasoconstrictors, albumin is useful in the management of patients with hepatorenal syndrome. Its role is being investigated in a large number of indications, which rely on its volume and nonvolume expansion functions such as stroke, severe sepsis, Alzheimer's disease, malaria, burns, and ovarian hyperstimulation syndrome. This review explores the above concepts, reviews the available evidence for the use of albumin in liver diseases, defines therapeutic limitations, and explores the challenges that should be addressed in future research.

Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: a systematic review and meta-analysis

BACKGROUND

Studies have suggested that albumin has a value in cirrhotic patients undergoing paracentesis but its value in infection and sepsis is less clear. We planned to perform a meta-analysis of the risk of adverse outcomes in cirrhotic patients with and without albumin use.

METHODS

We searched MEDLINE and EMBASE in January 2013 for randomized studies of cirrhotic patients that reported the risk of adverse events and mortality with albumin and no albumin exposure. We performed random effects meta-analysis and assessed heterogeneity using the I² statistic.

RESULTS

Our review included 16 studies covering 1,518 patients. The use of albumin in paracentesis was associated with significantly reduced risk of paracentesis-induced circulatory dysfunction (OR 0.26 95%, CI 0.08-0.93) and there was a nonsignificant difference in death, encephalopathy, hyponatraemia, readmission, and renal impairment. Compared to the other volume expanders, albumin use showed no difference in clinical outcomes. In cirrhotic patients with any infection, there was a significant reduction in mortality (OR 0.46 95%, CI 0.25-0.86) and renal impairment (OR 0.34 95%, CI 0.15-0.75) when albumin was used.

CONCLUSION

The use of albumin in cirrhotic patients is valuable in patients with any infection and it reduces the risk of circulatory dysfunction among patients undergoing paracentesis.

NT-proBNP Changes in Patients with Ascites during Large Volume Paracentesis

Background. N-terminal probrain natriuretic peptide (NT-proBNP) is a hormone involved in the regulation of cardiovascular homeostasis. Changes in serum NT-proBNP during large volume paracentesis (LVP) in patients with ascites have never before been examined. Aims. To determine if significant changes in serum NT-proBNP occur in patients undergoing LVP and the associated clinical correlates in patients with cirrhosis. Method. A total of 45 patients with ascites were prospectively recruited. Serum NT-proBNP, biochemistry, and haemodynamics were determined at baseline and at key time points during and after paracentesis. Results. 34 patients were analysed; 19 had ascites due to cirrhosis and 15 from malignancy. In those with cirrhosis, NT-proBNP decreased by 77.3 pg/mL at 2 L of drainage and 94.3 pg/mL at the end of paracentesis, compared with an increase of 10.5 pg/mL and 77.2 pg/mL in cancer patients at the same time points (P = 0.05 and P = 0.03). Only congestive cardiac failure (CCF) was an independent predictor of significant NT-proBNP changes at the end of drainage in cirrhotic patients (P < 0.01). There were no significant changes in haemodynamics or renal biochemistry for either group. Conclusion. Significant reductions in serum NT-proBNP during LVP occur in patients with cirrhosis but not malignancy, and only comorbid CCF appeared to predict such changes.

Automated low flow pump system for the treatment of refractory ascites: a multi-center safety and efficacy study

BACKGROUND & AIMS

Refractory ascites (RA) affects 10% of patients with advanced cirrhosis and ascites. Usual therapy includes large volume paracentesis, and in selected patients, a transjugular portosystemic shunt (TIPS). These therapies may be associated with increased morbidity: paracentesis may induce circulatory dysfunction and impair quality of life and TIPS may induce encephalopathy and is associated with increased mortality in patients with severe liver dysfunction. We present the results of a multicenter, non-randomized trial to assess the safety and efficacy of a new automated pump system for treatment of RA.

METHODS

Forty patients at 9 centers (February 2010-June 2011) received an implanted pump for the automated removal of ascites from the peritoneal cavity into the bladder, from where it was eliminated through normal urination. Patients were followed-up for 6months. The primary study outcome was safety. Secondary outcomes included recurrence of tense ascites and pump performance.

RESULTS

Surgical complications occurred early in the study and became less frequent. The pump system removed 90% of the ascites and significantly reduced the median number of large volume paracentesis per month [3.4 (range 1-6) vs. 0.2 (range 0-4); p <0.01]. Cirrhosis-related adverse events decreased along follow-up.

CONCLUSIONS

The automated pump seems an efficacious tool to move out ascites from the peritoneal cavity to the bladder. Its safety is still moderate, but a broad use in different countries will improve the surgical technique as well as the medical surveillance. A prospective randomized clinical trial vs. large volume paracentesis is underway to confirm these preliminary results.