"Pleurex Desalination" in Malignancy-related Ascites: A Novel Mechanism of Hyponatremia

Daily Low-Volume Paracentesis and Clinical Complications in Patients With Refractory Ascites

Importance

The potential association of low-volume paracentesis of less than 5 L with complications in patients with ascites remains unclear, and individuals with cirrhosis and refractory ascites (RA) treated with devices like Alfapump or tunneled-intraperitoneal catheters perform daily low-volume drainage without albumin substitution. Studies indicate marked differences regarding the daily drainage volume between patients; however, it is currently unknown if this alters the clinical course.

Objective

To determine whether the incidence of complications, such as hyponatremia or acute kidney injury (AKI), is associated with the daily drainage volume in patients with devices.

Design, Setting, and Participants

This retrospective cohort study of patients with liver cirrhosis, RA, and a contraindication for a transjugular intrahepatic portosystemic shunt who received either device implantation or standard of care (SOC; ie, repeated large-volume paracentesis with albumin infusion), and were hospitalized between 2012 and 2020 were included. Data were analyzed from April to October 2022.

Interventions

Daily ascites volume removed.

Main outcomes and Measures

The primary end points were 90-day incidence of hyponatremia and AKI. Propensity score matching was performed to match and compare patients with devices and higher or lower drainage volumes to those who received SOC.

Results

Overall, 250 patients with RA receiving either device implantation (179 [72%] patients; 125 [70%] male; 54 [30%] female; mean [SD] age, 59 [11] years) or SOC (71 [28%] patients; 41 [67%] male; 20 [33%] female; mean [SD] age, 54 [8]) were included in this study. A cutoff of 1.5 L/d or more was identified to estimate hyponatremia and AKI in the included patients with devices. Drainage of 1.5 L/d or more was associated with hyponatremia and AKI, even after adjusting for various confounders (hazard ratio [HR], 2.17 [95% CI, 1.24-3.78]; P = .006; HR, 1.43 [95% CI, 1.01-2.16]; P = .04, respectively). Moreover, patients with taps of 1.5 L/d or more and less than 1.5 L/d were matched with patients receiving SOC. Those with taps of 1.5 L/d or more had a higher risk of hyponatremia and AKI compared with those receiving SOC (HR, 1.67 [95% CI, 1.06-2.68]; P = .02 and HR, 1.51 [95% CI, 1.04-2.18]; P = .03), while patients with drainage of less than 1.5 L/d did not show an increased rate of complications compared with those receiving SOC.

Conclusions and Relevance

In this cohort study, clinical complications in patients with RA performing low-volume drainage without albumin infusion were associated with the daily volume drained. Based on this analysis, physicians should be cautious in patients performing drainage of 1.5 L/d or more without albumin infusion.

Water transport regulates nucleus volume, cell density, Young's modulus, and E-cadherin expression in tumor spheroids

Cell volume is maintained by the balance of water and solutes across the cell membrane and plays an important role in mechanics and biochemical signaling in cells. Here, we assess the relationship between cell volume, mechanical properties, and E-cadherin expression in three-dimensional cultures for ovarian cancer. To determine the effect of water transport in multi-cellular tumors, ovarian cancer spheroids were subjected to hypotonic and hypertonic shock using water and sucrose mixtures, respectively. Increased osmolality resulted in decreased nucleus volume, increased Young's modulus, and increased tumor cell density in ovarian cancer spheroids. Next, we looked at the reversibility of mechanics and morphology after 5 min of osmotic shock and found that spheroids had a robust ability to return to their original state. Finally, we quantified the size of E-cadherin clusters at cell-cell junctions and observed a significant increase in aggregate size following 30 min of hypertonic and hypotonic osmotic shocks. Yet, these effects were not apparent after 5 min of osmotic shock, illustrating a temporal difference between E-cadherin regulation and the immediate mechanical and morphology changes. Still, the osmotically induced E-cadherin aggregates which formed at the 30-minute timepoint was reversible when spheroids were replenished with isotonic medium. Altogether, this work demonstrated an important role of osmolality in transforming mechanical, morphology, and molecular states.

Home-based, tunnelled peritoneal drainage system as an alternative treatment option for patients with refractory ascites

BACKGROUND

Onset of refractory ascites is the hallmark of end-stage liver disease. If liver transplantation (LTx) is not available and contraindications for a transjugular portosystemic shunt (TIPS) are present, repeated paracentesis remains the standard of care (SOC). Home-based, tunnelled peritoneal catheters (PeCa) have been suggested as an alternative treatment option. However, data on patients with cirrhosis are scarce.

AIM

To evaluate the safety of PeCa in these patients compared to SOC.

METHODS

Overall, 223 patients with cirrhosis, a contraindication for TIPS and refractory ascites were included in this retrospective study. PeCa implant was performed in 152 patients, whereas 71 were treated with SOC. Analysed end points included device explant-free survival, mortality, acute kidney injury (AKI) and hyponatraemia. In the second approach, propensity score matching (PPSM) was performed to adjust for confounding factors.

RESULTS

In patients with PeCa, median device explant-free survival was 74 days and 52 explants were recorded within the first 90 days. Within 90 days, patients with PeCa had lower mortality than SOC (p = 0.11), and spontaneous bacterial peritonitis (SBP) incidence did not differ (p = 0.82). Regarding AKI and hyponatraemia, there was a trend towards a higher incidence in the PeCa group (p = 0.13 and p = 0.08), and the risk for rehospitalisation was higher in those with a PeCa (HR: 2.11, p = 0.04). After PPSM, mortality was lower in the PeCa group (HR:0.40; p = 0.03), whereas the incidence of SBP and hyponatraemia was comparable (p = 0.80 and p = 0.28) and AKI was more frequent in those with a PeCa (p = 0.08).

CONCLUSION

The implant of PeCa allows home-based therapy of patients with cirrhosis and refractory ascites and a contraindication for TIPS. However, the risk for complications has to be considered and prospective studies are needed.

Incidence of Hyponatremia in Patients With Indwelling Peritoneal Catheters for Drainage of Malignant Ascites

IMPORTANCE

Indwelling peritoneal catheters (IPCs) are frequently used to drain tense, symptomatic, malignant ascites. Large-volume drainage may lead to hyponatremia owing to massive salt depletion. To date, no studies have examined the epidemiology of hyponatremia after placement of an IPC.

OBJECTIVE

To evaluate the incidence of hyponatremia after IPC placement, the risk factors associated with its development, and how it is managed.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study retrospectively reviewed the medical records of 461 patients who had IPCs placed during the period between 2006 and 2016 at a tertiary care hospital in Boston, Massachusetts, of whom 309 patients met the inclusion criteria. Data analysis was performed from June to November 2019.

MAIN OUTCOMES AND MEASURES

Main outcomes were the incidence of hyponatremia (with a serum sodium level <135 mEq/L) after IPC placement, the risk factors for its development, and how it was managed. We also examined the clinical course of a subset of 21 patients with hypovolemic hyponatremia.

RESULTS

Of the 309 eligible patients with laboratory results both before IPC placement and 2 days or more after IPC placement, 189 (72.1%) were female, and the mean (SD) age was 59 (12) years. The overall incidence of hyponatremia after IPC placement was 84.8% (n = 262), of whom 21 patients (8.0%) had severe hyponatremia. The mean (SD) decrease in serum sodium level before vs after IPC placement was 5 (5.1) mEq/L and decreased by 10 mEq/L or more among 52 patients (16.8%). Patients with hyponatremia prior to IPC placement had an 8-fold higher adjusted odds of having persistent hyponatremia after IPC placement (odds ratio, 7.9; 95% CI, 2.9-21.7). Patients with hepatopancreatobiliary malignant neoplasms were more likely to develop hyponatremia (78 of 262 patients with hyponatremia [29.8%] vs 7 of 47 patients without hyponatremia [14.9%]). Hyponatremia was either unrecognized or untreated in 189 patients (72.1%).

CONCLUSIONS AND RELEVANCE

Although the placement of an IPC is often a palliative measure, hyponatremia is common and is often untreated or unrecognized. Patients at highest risk, such as those with hyponatremia at baseline and those with hepatopancreatobiliary malignant neoplams, should be evaluated carefully prior to IPC placement and may warrant closer monitoring after placement. In all cases, hyponatremia should be evaluated and managed within the context of a patient's overall goals of care.