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

Role of albumin infusion in cirrhosis-associated complications

Cirrhosis is an advanced-stage liver disease that occurs due to persistent physiological insults such as excessive alcohol consumption, infections, or toxicity. It is characterised by scar tissue formation, portal hypertension, and ascites (accumulation of fluid in the abdominal cavity) in decompensated cirrhosis. This review evaluates how albumin infusion ameliorates cirrhosis-associated complications. Since albumin is an oncotic plasma protein, albumin infusion allows movement of water into the intravascular space, aids with fluid resuscitation, and thereby contributes to resolving cirrhosis-induced hypovolemia (loss of extracellular fluid) seen in ascites. Thus, albumin infusion helps prevent paracentesis-induced circulatory dysfunction, a complication that occurs when treating ascites. When cirrhosis advances, other complications such as spontaneous bacterial peritonitis and hepatorenal syndrome can manifest. Infused albumin helps mitigate these by exhibiting plasma expansion, antioxidant, and anti-inflammatory functions. In hepatic encephalopathy, albumin infusion is thought to improve cognitive function by reducing ammonia concentration in blood and thereby tackle cirrhosis-induced hepatocyte malfunction in ammonia clearance. Infused albumin can also exhibit protective effects by binding to the cirrhosis-induced proinflammatory cytokines TNFα and IL6. While albumin administration has shown to prolong overall survival of cirrhotic patients with ascites in the ANSWER trial, the ATTIRE and MACHT trials have shown either no effect or limitations such as development of pulmonary oedema and multiorgan failure.  Thus, albumin infusion is not a generic treatment option for all cirrhosis patients. Interestingly, cirrhosis-induced structural alterations in native albumin (which lead to formation of different albumin isoforms) can be used as prognostic biomarkers because specific albumin isoforms indicate certain complications of decompensated cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt Reductions

Transjugular intrahepatic portosystemic shunts (TIPS) are effective in reducing the portosystemic gradient and relieving complications of portal hypertension. Despite optimal patient selection, TIPS placement can be limited due to worsening hepatic encephalopathy and liver failure. In these cases, TIPS reduction may be necessary. A brief history of TIPS reduction and techniques for reduction are reviewed.

Large volume paracentesis of 39.5 liters chylous ascites in the setting of high-grade follicular lymphoma

The American Association for the Study of Liver Diseases recognizes large volume paracentesis as draining greater than 5 liters of ascites and states there is no limit in the amount of ascites drained with appropriate replacement of albumin. For many practitioners performing safe large volume paracentesis between 5 and 10 liters or even 20 liters is not an uncommon practice. However, drainage of higher volumes outside common practice may raise concerns of patient intolerance and complication. The largest volume paracentesis reported in the literature to date is 41 liters. However, few other reports approach this volume. This case report demonstrates patient tolerance of a 39.5-liter paracentesis performed with close monitoring and hypertonic albumin replacement in a patient with chylous ascites due to high-grade follicular lymphoma.

Cardiovascular manifestation of end-stage liver disease and perioperative echocardiography for liver transplantation: anesthesiologist’s view

Liver transplantation (LT) is the curative therapy for decompensated cirrhosis. However, anesthesiologists can find it challenging to manage patients undergoing LT due to the underlying pathologic conditions of patients with end-stage liver disease and the high invasiveness of the procedure, which is frequently accompanied by massive blood loss. Echocardiography is a non-invasive or semi-invasive imaging tool that provides real-time information about the structural and functional status of the heart and is considered to be able to improve outcomes by enabling accurate and detailed assessments. This article reviews the pathophysiologic changes of the heart accompanied by cirrhosis that mainly affect hemodynamics. We also present a comparative review of the diagnostic criteria for cirrhotic cardiomyopathy published by the World Congress of Gastroenterology in 2005 and the Cirrhotic Cardiomyopathy Consortium in 2019. This article discusses the conditions that could affect hemodynamic stability and postoperative outcomes, such as coronary artery disease, left ventricular outflow tract obstruction, portopulmonary hypertension, hepatopulmonary syndrome, pericardial effusion, cardiac tamponade, patent foramen ovale, and ascites. Finally, we cover a number of intraoperative factors that should be considered, including intraoperative blood loss, rapid reaccumulation of ascites, manipulation of the inferior vena cava, post-reperfusion syndrome, and adverse effects of excessive fluid infusion and transfusion. This article aimed to summarize the cardiovascular manifestations of cirrhosis that can affect hemodynamics and can be evaluated using perioperative echocardiography. We hope that this article will provide information about the hemodynamic characteristics of LT recipients and stimulate more active use of perioperative echocardiography.

Prevalence, risk factors, and short-term outcomes of postparacentesis acute kidney injury using revised criteria of the international club of ascites

Acute kidney injury (AKI) can become complicated after paracentesis due to extrarenal fluid loss and inadequate blood flow to the kidneys. The objective of this study was to explore the incidence and clinical implications of postparacentesis AKI.A retrospective cohort of 137 liver cirrhosis patients (mean age: 61.3 ± 11.8 years, male: 100 [73.0%], viral hepatitis: 93 [67.9%]) who underwent paracentesis was analyzed. The incidence of AKI as defined by the international club of ascites (ICA) criteria, the risk factors, and its impact on early mortality were all assessed.Thirty two patients (23.4%) developed AKI after paracentesis. In multivariate analysis, the Model for end-stage liver disease (MELD)-Na score was an independent factor associated with AKI development (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.07-1.23) after paracentesis. The incidence of early mortality was significantly higher for those with AKI than without AKI (71.9% [23/32 patients] vs 11.4% [12/105 patients], P < .001). AKI (hazard ratio [HR], 7.56; 95% CI, 3.40-16.8) and MELD-Na score (HR, 1.08; 95% CI, 1.02-1.14) were independent factors associated with early mortality. In subgroup analysis, AKI after paracentesis was associated with significantly higher early mortality in both MELD-Na groups, that is, patients with a MELD-Na score >26 (87.5% vs 22.2%, P < .001) and those with a MELD-Na score ≤26 (56.3% vs 9.2%, P < .001).Postparacentesis AKI occurred frequently in cirrhotic patients. Furthermore, it was associated with early mortality. Baseline MELD-Na score was associated with AKI, indicating that careful attention is required for those with a higher MELD-Na score who are being considered for therapeutic paracentesis.

Effect of large volume paracentesis performed just prior to transjugular intrahepatic portosystemic shunt on the anesthetic management during the procedure

Background and Aims:

Patients often undergo paracentesis prior to a transjugular intrahepatic portosystemic shunt (TIPS) procedure to improve respiratory mechanics. However, the effect of large volume paracentesis (LVP) on intraoperative hemodynamics and anesthetic management when it is performed immediately before the TIPS procedure is not well documented.

Material and Methods:

This is a retrospective study in patients undergoing the TIPS procedure between 2004 and 2017. Patients were divided into two groups based on the volume of preoperative paracentesis, namely, small volume paracentesis (SVP), defined as paracentesis volume less than 5 L and LVP, defined as paracentesis volume of at least 5 L. Patients' demographics and perioperative information were collected through chart review. The Wilcoxon signed-rank test, student's t-test, and Fisher's exact test were used when appropriate. Uni- and multivariate linear regression analyses were used to determine the predictive value of paracentesis volume in relation to intraoperative hemodynamics and management of hypotension.

Results:

Of 49 patients, 19 (39%) received LVP and the remainder received SVP. Baseline demographics were comparable between groups as were intraoperative hypotension and volume of infused crystalloid and colloid. However, vasopressor use (P = 0.02) and packed red blood cell transfusion (P = 0.01) were significantly higher in the large volume group. Paracentesis volume was an independent predictor of the phenylephrine dose (P = 0.0004), and of crystalloid (P = 0.05) and colloid (P = 0.009) volume administered after adjusting for age, sex, body mass index, alcohol use, hemoglobin, and model for end-stage liver disease score.

Conclusion:

The anesthetic management of patients who undergo LVP just prior to a TIPS procedure may require larger doses of vasopressors and colloids to prevent intraoperative hemodynamic instability during the TIPS placement but may be as well tolerated as SVP.

Management of Refractory Ascites Due to Portal Hypertension: Current Status

Refractory ascites is a costly and debilitating condition that occurs most frequently in the setting of substantial cirrhotic portal hypertension, where it portends a poor prognosis. Many treatment options are available, among them medical management, serial large volume paracenteses, transjugular intrahepatic portosystemic shunts, and implanted drainage devices. Although the availability of multiple therapies ensures that most patients will achieve satisfactory results, it can be challenging for the provider to select the appropriate treatment for each specific patient. This article reviews the available therapeutic options for refractory ascites and incorporates available data and clinical experience to suggest a linear stepwise management approach to enhance patient outcomes.

Human albumin solutions in intensive care: A review

Albumin plays a key role in the critically ill patient acting as a prognostic marker and as a therapy in the form of human albumin solutions. However, the use of human albumin solution has varied over time with notable differences between health systems. Whilst its use is widely accepted for some clinical indications, its role has not always been clear in the critically ill and has been found to be harmful in some cohorts. Numerous studies have showed conflicting results and critical care clinicians have not always been guided by robust evidence. Nonetheless, at present the use of human albumin solution appears to be increasing again in the United Kingdom. Below, we discuss the latest evidence base for its use in critically ill patients.

Could KIM-1 and NGAL levels predict acute kidney injury after paracentesis? - preliminary study

Background

Kidney dysfunction is a common complication in patients with severe liver cirrhosis. There is a need for discovery and validation of novel biomarkers for earlier AKI detection. The aim of this study was to determine if tubular injury markers: NGAL and KIM-1 could be helpful in the early diagnosis of AKI in patients undergoing therapeutic paracentesis.

Methods

This preliminary study included 24 adult patients diagnosed with liver cirrhosis who had been hospitalized due to massive ascites requiring paracentesis. Pre- and post-paracentesis plasma samples were taken from each patient and biomarkers were measured.

Results

Before paracentesis, the levels of serum and urinary NGAL were similar between patients and controls; while urinary KIM-1 was markedly increased in liver cirrhotic patients (0.76 vs. 0.24 ng/ml; respectively). Although urinary NGAL levels in AKI patients were 5-time greater than in non-AKI subgroup, the difference did not reach statistical significance (13.2 vs 1.5 pg/mL, p = 0.06). Serum NGAL level, post-procedure, was 3 times greater in AKI subgroup.

Conclusion

Kidney injury markers, especially serum NGAL, may be useful for the early detection of AKI. However, further research is required to determine if biomarkers of kidney injury may help identify patients with cirrhosis who would most likely benefit from early AKI prevention and treatment.

Verification of serum albumin elevating effect of cell-free and concentrated ascites reinfusion therapy for ascites patients: a retrospective controlled cohort study

Cell-free and concentrated ascites reinfusion therapy (CART) is frequently used to treat refractory ascites in Japan. However, its efficacy remains unclear. This controlled cohort study verified the serum albumin elevating effect of CART by comparisons with simple paracentesis. Ascites patients receiving CART (N = 88) or paracentesis (N = 108) at our hospital were assessed for the primary outcome of change in serum albumin level within 3 days before and after treatment. A significantly larger volume of ascites was drained in the CART group. The change in serum albumin level was +0.08 ± 0.25 g/dL in the CART group and −0.10 ± 0.30 g/dL in the paracentesis group (P < 0.001). The CART – paracentesis difference was +0.26 g/dL (95%CI +0.18 to +0.33, P < 0.001) after adjusting for potential confounders by multivariate analysis. The adjusted difference increased with drainage volume. In the CART group, serum total protein, dietary intake, and urine volume were significantly increased, while hemoglobin and body weight was significantly decreased, versus paracentesis. More frequent adverse events, particularly fever, were recorded for CART, although the period until re-drainage was significantly longer. This study is the first demonstrating that CART can significantly increase serum albumin level as compared with simple paracentesis. CART represents a useful strategy to manage patients requiring ascites drainage.

Paracentesis-induced acute kidney injury in decompensated cirrhosis - prevalence and predictors

AIM OF THE STUDY

A subgroup of cirrhotic patients undergoing therapeutic paracentesis develop acute kidney injury (AKI) despite adequate colloidal replacement.The aim of the study was to determine the prevalence and predictors of paracentesis-induced AKI in cirrhotic patients with normal baseline renal parameters and adequate colloidal replacement.

MATERIAL AND METHODS

This prospective, observational analytical study was undertaken between April 2015 and April 2017. All patients undergoing therapeutic paracentesis were enrolled as per inclusion and exclusion criteria. Based on Acute Kidney Injury Network (AKIN) criteria for AKI, comparative analysis was performed between those developing and not developing AKI for demography, renal parameters, frequency and quantity of paracentesis per session. Univariate and multivariate regression analyses were performed to determine the predictors of AKI.

RESULTS

Altogether, 177 patients underwent 859 therapeutic paracenteses. Ninety-four paracentesis sessions resulted in an AKI (10.9%). The median number of paracenteses was 10 (range 1-25) and the median volume of fluid drained per paracentesis was 6 l (1-20 l). In univariate analysis, younger age (p < 0.02), higher MELD (Model For End-Stage Liver Disease) score (p < 0.0001), CTP (Child-Turcotte-Pugh) class C (p < 0.017) and prior history of renal dysfunction (p < 0.0001) were significantly associated with AKI. For each liter of fluid drained, the risk of AKI increased by 1.24 times. Frequency of paracentesis did not influence the AKI. In multivariate logistic regression, the significant predictors of AKI were past renal dysfunction, a higher MELD and volume of fluid tapped at paracentesis.

CONCLUSIONS

Post-paracentesis AKI occurs in 10.9% of cases, despite adequate colloid replacement. For each 1 l of fluid drained during paracentesis, the risk of AKI increased by 1.24 times.

Standardizing the Use of Albumin in Large Volume Paracentesis

Background

Albumin after large volume paracentesis (LVP) reduces paracentesis-induced circulatory dysfunction (PICD). The most efficacious dose of albumin for LVP is unclear.

Objective

To evaluate the impact of implementing a standardized LVP order set on albumin utilization and patient outcomes.

Methods

This is a retrospective review of patients with ascites due to cirrhosis who received a therapeutic paracentesis at a large, academic institution. Primary outcome was amount of albumin used prior to and after order set implementation. Albumin doses were standardized in the order set to 25 g (5-6 L removed), 50 g (7-10 L), and 75 g (>10 L). Patient outcomes were rates of hyponatremia, renal impairment, and hypotension.

Results

There were 100 patients included in each arm of the final analysis. Patients prior to order set implementation received a higher amount of albumin per liter removed compared to those post-implementation (8.3 g/L vs 6.5 g/L, respectively; P < .01). There were no significant differences between groups in absolute changes in serum sodium (0 mEq/L vs −1 mEq/L, P = .64), serum creatinine (0.06 mg/dL vs 0.05 mg/dL, P = .94), or systolic blood pressure (−4 mm Hg vs −3 mm Hg, P = .96). There were no differences between groups in rates of hyponatremia (1.6% vs 6.6%, P = .21), renal impairment (11.3% vs 11.5%, P = .97), or hypotension (17.4% vs 17.6%, P = .97).

Conclusions

Use of an order set to guide albumin dosing based on amount of ascitic fluid removed during LVP resulted in a significant reduction in the amount of albumin given with no difference in adverse effects.

Paracentesis in cirrhotics is associated with increased risk of 30-day readmission

AIM

To determine the readmission rate, its reasons, predictors, and cost of 30-d readmission in patients with cirrhosis and ascites.

METHODS

A retrospective analysis of the nationwide readmission database (NRD) was performed during the calendar year 2013. All adults cirrhotics with a diagnosis of ascites, spontaneous bacterial peritonitis, or hepatic encephalopathy were identified by ICD-9 codes. Multivariate analysis was performed to assess predictors of 30-d readmission and cost of readmission.

RESULTS

Of the 59597 patients included in this study, 18319 (31%) were readmitted within 30 d. Majority (58%) of readmissions were for liver related reasons. Paracentesis was performed in 29832 (50%) patients on index admission. Independent predictors of 30-d readmission included age < 40 (OR: 1.39; CI: 1.19-1.64), age 40-64 (OR: 1.19; CI: 1.09-1.30), Medicaid (OR: 1.21; CI: 1.04-1.41) and Medicare coverage (OR: 1.13; CI: 1.02-1.26), > 3 Elixhauser comorbidity (OR: 1.13; CI: 1.05-1.22), nonalcoholic cirrhosis (OR: 1.16; CI: 1.10-1.23), paracentesis on index admission (OR: 1.28; CI: 1.21-1.36) and having hepatocellular carcinoma (OR: 1.21; CI: 1.05; 1.39). Cost of index admission was similar in patients readmitted and not readmitted (P-value: 0.34); however cost of care was significantly more on 30 d readmission ($30959 ± 762) as compared to index admission ($12403 ± 378), P-value: < 0.001.

CONCLUSION

Cirrhotic patients with ascites have a 33% chance of readmission within 30-d. Younger patients, with public insurance, nonalcoholic cirrhosis and increased comorbidity who underwent paracentesis are at increased risk of readmission. Risk factors for unplanned readmission should be targeted given these patients have higher healthcare utilization.

The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction

Background/Aims

Ascites is a dreadful complication of liver cirrhosis associated with short survival. Large volume paracentesis (LVP) is used to treat tense or refractory ascites. Paracentesis induced circulatory dysfunction (PICD) develops if no plasma expanders are given with ominous complications. To study the effect of ascites flow rate on PICD development.

Methods

Sixty patients with cirrhosis and tense ascites underwent LVP of 8 L were randomized into 3 equal groups of different flow rate extraction; group I (80 mL/minute), group II (180 mL/minute) and group III (270 mL/minute). Plasma renin activity (PRA) was measured baseline and on day six. PICD was defined as increase in PRA >50% of the pretreatment value.

Results

In group I through 3; the mean age was (52.5±9.4 vs. 56.4±8.5 vs. 55.8±7.1 years; P>0.05), mean arterial pressure (81.4±5.6 vs. 81.5±7 vs. 79.5±7.2 mmHg; P>0.05), MELD (17.6±4.1 vs. 15.8±4.1 vs. 14.7±4.5). Baseline PRA was comparable (1,366.0±1244.9 vs. 1,151.3±1,444.8 vs. 951.9±1,088 pg/mL; P>0.05). There was no statistically significant (P>0.05) flow mediated changes (Δ) of creatinine (0.23±0.27 vs. 0.38±0.33 vs. 0.26±0.18 mg/dL), MELD (1.25±5.72 vs. 1.70±2.18 vs. 1.45±2.21) or PRA (450.93±614.10 vs. 394.61±954.64 vs. 629.51±1,116.46 pg/mL). PICD was detected in a similar frequency in the three groups (P>0.05). On univariate logistic analysis only female sex was a fairly significant PICD predictor (Wald 3.85, odds ratio 3.14; P=0.05).

Conclusions

The ascites flow rate does not correlate with PICD development.