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Hasan I, Murti IS, Bayupurnama P, Kalista KF, Hill-Zabala C, Kananda D, Viayna E. Cost-effectiveness of albumin in the treatment of decompensated cirrhosis in resource-limited healthcare settings. Drugs Context 2024; 13:2024-1-1. [PMID: 38699066 PMCID: PMC11065133 DOI: 10.7573/dic.2024-1-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 05/05/2024] Open
Abstract
Background Human albumin (HA) is an effective adjuvant treatment for patients with cirrhosis developing spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and ascites requiring large-volume paracentesis (LVP). However, cost remains a barrier to use, particularly in resource-limited settings. This study aims to assess the cost-effectiveness of HA in patients with cirrhosis with SBP, HRS or ascites requiring LVP in the Indonesian healthcare system as a representative of a resource-limited setting. Methods Three decision-tree models were developed to assess the cost-effectiveness of (1) antibiotics and HA versus antibiotics alone in patients with SBP, (2) terlipressin and HA versus terlipressin alone in patients with HRS, and (3) LVP and HA versus LVP and gelatine for patients with ascites. Clinical utility and economic inputs were pooled from the available literature. Time horizon was 3 months. Outcomes were expressed as incremental cost-effectiveness ratios (ICER) reported as 2021 IDR per quality-adjusted life year (QALY) (exchange rate June 30, 2021: 1 EUR = 17,245 IDR). Willingness-to-pay thresholds considered were: three times the GDP per capita (199,355,561 IDR/QALY; 11,560 EUR/QALY) and one time the GDP per capita (66,451,854 IDR/QALY; 3853 EUR/QALY). Results The ICER for antibiotics and HA (versus antibiotics alone) for SBP was 80,562,652 IDR per QALY gained (4672 EUR/QALY). The ICER for terlipressin and HA (versus terlipressin) for HRS was 23,085,004 IDR per QALY gained (1339 EUR/QALY). The ICER for LVP and HA versus LVP and gelatine was 24,569,827 IDR per QALY gained (1425 EUR/QALY). Conclusion Adjunctive HA may be a cost-effective treatment for SBP, HRS and LVP in resource-limited settings.
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Affiliation(s)
- Irsan Hasan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Ignatia Sinta Murti
- Department of Internal Medicine, Abdul Wahab Sjahranie General Hospital Samarinda, East Kalimantan, Indonesia
| | - Putut Bayupurnama
- Gastroenterology & Hepatology Division, Department of Internal Medicine, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Kemal Fariz Kalista
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
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Kugelmas M, Loftus M, Owen EJ, Wadei H, Saab S. Expert perspectives for the pharmacist on facilitating and improving the use of albumin in cirrhosis. Am J Health Syst Pharm 2023; 80:806-817. [PMID: 37013893 PMCID: PMC10287532 DOI: 10.1093/ajhp/zxad070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
PURPOSE Albumin, the most abundant and arguably most important protein in the human body, plays a unique role in decompensated cirrhosis because its structure and function are quantitatively and qualitatively affected. A literature review was performed to provide insights into albumin use. The manuscript was developed using a multidisciplinary approach; 2 hepatologists, a nephrologist, a hospitalist, and a pharmacist, who are all members of or work closely with the Chronic Liver Disease Foundation, collaborated to write this expert perspective review. SUMMARY Cirrhosis represents the potential end in the spectrum of all chronic liver diseases. Decompensated cirrhosis, defined by the overt manifestation of liver failure (eg, ascites, hepatic encephalopathy, variceal bleeding), is the inflection point associated with increased mortality. Human serum albumin (HSA) infusion serves an important role in the treatment of advanced liver disease. The benefits of HSA administration in patients with cirrhosis are widely accepted, and its use has been advocated by several professional societies. However, inappropriate HSA use can lead to significant adverse patient events. This paper discusses the rationale for the administration of HSA in the treatment of complications of cirrhosis, analyzes the data on the use of HSA in cirrhosis, and streamlines practical recommendations set forth in published guidance. CONCLUSION Use of HSA in clinical practice needs to be improved. The objective of this paper is to empower pharmacists to facilitate and improve the use of HSA in patients with cirrhosis at their practice sites.
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Affiliation(s)
| | - Michelle Loftus
- Division of Hospital Medicine, North Shore University Hospital, Hempstead, NY, and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Emily J Owen
- Critical Care, Surgical Burn Trauma Intensive Care Unit, Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Hani Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Sammy Saab
- Department of Internal Medicine and Surgery, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
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Bai Z, Wang L, Lin H, Tacke F, Cheng G, Qi X. Use of Human Albumin Administration for the Prevention and Treatment of Hyponatremia in Patients with Liver Cirrhosis: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11195928. [PMID: 36233795 PMCID: PMC9572637 DOI: 10.3390/jcm11195928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/15/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background. Hyponatremia is a common complication of liver cirrhosis and aggravates patients’ outcomes. It may be corrected by human albumin (HA) infusion. Herein, we have conducted a systematic review and meta-analysis to evaluate the efficacy of intravenous HA administration for the prevention and treatment of hyponatremia in liver cirrhosis. Methods. Literature was searched in the PubMed, EMBASE, and Cochrane Library databases. If possible, a meta-analysis would be conducted. Incidence of hyponatremia, rate of resolution of hyponatremia, and serum sodium level were compared between cirrhotic patients who received and did not receive HA infusion. Odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated. The quality of evidence was assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results. Initially, 3231 papers were identified. Among them, 30 studies, including 25 randomized controlled trials (RCTs) and 5 cohort studies, were eligible. Among cirrhotic patients without hyponatremia, the HA infusion group had significantly lower incidence of hyponatremia (OR = 0.55, 95%CI = 0.38–0.80, p = 0.001) and higher serum sodium level (MD = 0.95, 95%CI = 0.47–1.43, p = 0.0001) as compared to the control group. Among cirrhotic patients with hyponatremia, the HA infusion group had a significantly higher rate of resolution of hyponatremia (OR = 1.50, 95%CI = 1.17–1.92, p = 0.001) as compared to the control group. Generally, the quality of available evidence is low. Conclusions. Based on the current evidence, HA may be considered for preventing the development of hyponatremia in liver cirrhosis, especially in those undergoing LVP, and treating hyponatremia. Well-designed studies are required to clarify the effects of HA infusion on hyponatremia in liver cirrhosis.
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Affiliation(s)
- Zhaohui Bai
- NMPA Key Laboratory for Research and Evaluation of Drug Regulatory Technology, Shenyang Pharmaceutical University, Shenyang 110016, China
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Hanyang Lin
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité University Medical Center, 10117 Berlin, Germany
| | - Gang Cheng
- NMPA Key Laboratory for Research and Evaluation of Drug Regulatory Technology, Shenyang Pharmaceutical University, Shenyang 110016, China
- Correspondence: (G.C.); (X.Q.)
| | - Xingshun Qi
- NMPA Key Laboratory for Research and Evaluation of Drug Regulatory Technology, Shenyang Pharmaceutical University, Shenyang 110016, China
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, China
- Correspondence: (G.C.); (X.Q.)
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de Mattos ÂZ, Simonetto DA, Terra C, Farias AQ, Bittencourt PL, Pase THS, Toazza MR, de Mattos AA. Albumin administration in patients with cirrhosis: Current role and novel perspectives. World J Gastroenterol 2022; 28:4773-4786. [PMID: 36156923 PMCID: PMC9476855 DOI: 10.3748/wjg.v28.i33.4773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/05/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
Mortality in cirrhosis is mostly associated with the development of clinical decompensation, characterized by ascites, hepatic encephalopathy, variceal bleeding, or jaundice. Therefore, it is important to prevent and manage such complications. Traditionally, the pathophysiology of decompensated cirrhosis was explained by the peripheral arterial vasodilation hypothesis, but it is currently understood that decompensation might also be driven by a systemic inflammatory state (the systemic inflammation hypothesis). Considering its oncotic and nononcotic properties, albumin has been thoroughly evaluated in the prevention and management of several of these decompensating events. There are formal evidence-based recommendations from international medical societies proposing that albumin be administered in individuals with cirrhosis undergoing large-volume paracentesis, patients with spontaneous bacterial peritonitis, those with acute kidney injury (even before the etiological diagnosis), and those with hepatorenal syndrome. Moreover, there are a few randomized controlled trials and meta-analyses suggesting a possible role for albumin infusion in patients with cirrhosis and ascites (long-term albumin administration), individuals with hepatic encephalopathy, and those with acute-on-chronic liver failure undergoing modest-volume paracentesis. Further studies are necessary to elucidate whether albumin administration also benefits patients with cirrhosis and other complications, such as individuals with extraperitoneal infections, those hospitalized with decompensated cirrhosis and hypoalbuminemia, and patients with hyponatremia.
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Affiliation(s)
- Ângelo Zambam de Mattos
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
| | - Douglas Alano Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, United States
| | - Carlos Terra
- Department of Gastroenterology, State University of Rio de Janeiro, Rio de Janeiro 20550-170, Brazil
| | | | | | - Tales Henrique Soares Pase
- Internal Medicine Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Marlon Rubini Toazza
- Gastroenterology and Hepatology Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Angelo Alves de Mattos
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
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Use of human albumin infusion in cirrhotic patients: a systematic review and meta-analysis of randomized controlled trials. Hepatol Int 2022; 16:1468-1483. [PMID: 36048318 DOI: 10.1007/s12072-022-10374-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/04/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Human albumin infusion is effective for controlling systemic inflammation, thereby probably managing some liver cirrhosis-related complications, such as spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), and hepatorenal syndrome. However, its clinical benefits remain controversial. METHODS EMBASE, PubMed, and Cochrane Library databases were searched. Randomized controlled trials (RCTs) regarding use of human albumin infusion in cirrhotic patients were eligible. Mortality and incidence of liver cirrhosis-related complications were pooled. Effect of human albumin infusion on mortality was also evaluated by subgroup analyses primarily according to target population and duration of human albumin infusion treatment. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Forty-two RCTs were finally included. Meta-analysis showed that human albumin infusion could significantly decrease the mortality of cirrhotic patients (OR = 0.81, 95% CI = 0.67-0.98, p = 0.03). Subgroup analyses showed that human albumin infusion could significantly decrease the mortality of cirrhotic patients with SBP (OR = 0.36, 95% CI = 0.20-0.64, p = 0.0005) and HE (OR = 0.43, 95% CI = 0.22-0.85, p = 0.02), but not those with ascites or non-SBP infections or undergoing large-volume paracentesis. Short-term human albumin infusion treatment could significantly decrease short-term mortality (OR = 0.67, 95% CI = 0.50-0.89, p = 0.005), but not long-term mortality. Long-term human albumin infusion treatment could not significantly decrease long-term mortality (OR = 0.72, 95% CI = 0.48-1.08, p = 0.11). In addition, human albumin infusion could significantly decrease the incidence of renal impairment (OR = 0.63, 95% CI = 0.45-0.88, p = 0.007) and ascites (OR = 0.45, 95% CI = 0.25-0.81, p = 0.007), but not infections or gastrointestinal bleeding. CONCLUSIONS Human albumin infusion may improve the outcomes of cirrhotic patients. However, its indications for different complications and infusion strategy in liver cirrhosis should be further explored.
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Safety and efficacy of human serum albumin treatment in patients with cirrhotic ascites undergoing paracentesis: A systematic review and meta-analysis. Ann Hepatol 2021; 26:100547. [PMID: 34626828 DOI: 10.1016/j.aohep.2021.100547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 02/04/2023]
Abstract
Ascites is the most common presentation of decompensated liver cirrhosis. It is treated with therapeutic paracentesis which is associated with several complications. The role of human albumin in patients with cirrhotic ascites remains elusive and has been extensively studied with conflicting results. Thus, in order to fully appraise the available data we sought to perform this systematic review and meta-analysis. Herein we included studies comparing the efficacy and safety of human albumin comparing with other volume expanders and vasoactive agents in patients undergoing paracentesis in cirrhotic ascites. Odds ratio (OR) and mean difference (MD) were used to estimate the outcome with a 95% confidence interval (CI). Albumin use reduced the odds of paracentesis induced circulatory dysfunction (PICD) by 60% (OR 0.40, 95% CI 0.27-0.58). While performing subgroup analysis, albumin use lowered the odds of PICD significantly (OR 0.34, 95% CI 0.22-0.52) in comparison to other colloid volume expanders, but did not lower the odds of PICD in comparison to vasoconstrictor therapy (OR 0.93, 95% CI 0.35-2.45). Albumin was associated with a statistically significant lower incidence of hyponatremia (OR 0.59, 95% CI 0.39-0.88). Albumin did not reduce the overall mortality, readmission rate, recurrence of ascites, mean arterial pressure, incidence of renal impairment, hepatic encephalopathy, and gastrointestinal (GI) bleeding. Thus, treatment with albumin in cirrhotic ascites reduced PICD and hyponatremia although there was no benefit in terms of mortality, readmission rate, recurrence of ascites, hepatic encephalopathy, and GI bleeding.
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Walker SP, Bintcliffe O, Keenan E, Stadon L, Evison M, Haris M, Nagarajan T, West A, Ionescu A, Prudon B, Guhan A, Mustafa R, Herre J, Arnold D, Bhatnagar R, Kahan B, Miller RF, Rahman NM, Maskell NA. Randomised trial of indwelling pleural catheters for refractory transudative pleural effusions. Eur Respir J 2021; 59:13993003.01362-2021. [PMID: 34413152 DOI: 10.1183/13993003.01362-2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/27/2021] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | | | | | - Thapas Nagarajan
- Macclesfield General Hospital, East Cheshire NHS Trust, Macclesfield, UK
| | - Alex West
- Guy's and St Thomas' Hospital, London, UK
| | | | | | - Anur Guhan
- University Hospital Ayr, NHS Ayrshire and Arran, Ayrshire, UK
| | | | | | | | | | - Brennan Kahan
- MRC Clinical Trials Unit, University College London, London, UK
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8
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Pinchot JW, Kalva SP, Majdalany BS, Kim CY, Ahmed O, Asrani SK, Cash BD, Eldrup-Jorgensen J, Kendi AT, Scheidt MJ, Sella DM, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Radiologic Management of Portal Hypertension. J Am Coll Radiol 2021; 18:S153-S173. [PMID: 33958110 DOI: 10.1016/j.jacr.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022]
Abstract
Cirrhosis is a heterogeneous disease that cannot be studied as a single entity and is classified in two main prognostic stages: compensated and decompensated cirrhosis. Portal hypertension, characterized by a pathological increase of the portal pressure and by the formation of portal-systemic collaterals that bypass the liver, is the initial and main consequence of cirrhosis and is responsible for the majority of its complications. A myriad of treatment options exists for appropriately managing the most common complications of portal hypertension, including acute variceal bleeding and refractory ascites. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Sanjeeva P Kalva
- Panel Chair, Massachusetts General Hospital, Boston, Massachusetts, Chief, Division of Interventional Radiology, Massachusetts General Hospital
| | | | - Charles Y Kim
- Panel Vice-Chair, Duke University Medical Center, Durham, North Carolina, Chief, Division of Interventional Radiology, Duke University Medical Center
| | | | - Sumeet K Asrani
- Baylor University Medical Center, Dallas, Texas, American Association for the Study of Liver Diseases
| | - Brooks D Cash
- University of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas, American Gastroenterological Association
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts, Society for Vascular Surgery
| | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Director of Nuclear Medicine Therapy at Mayo Clinic Rochester
| | | | | | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, Chair, FMLH credentials committee, Division chief of IR at Medical College of Wisconsin
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Madoff DC, Cornman-Homonoff J, Fortune BE, Gaba RC, Lipnik AJ, Yarmohammadi H, Ray CE. Management of Refractory Ascites Due to Portal Hypertension: Current Status. Radiology 2021; 298:493-504. [PMID: 33497318 DOI: 10.1148/radiol.2021201960] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- David C Madoff
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Joshua Cornman-Homonoff
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Brett E Fortune
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Ron C Gaba
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Andrew J Lipnik
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Hooman Yarmohammadi
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
| | - Charles E Ray
- From the Department of Radiology and Biomedical Imaging, Section of Interventional Radiology, Yale School of Medicine, 330 Cedar St, TE-2, New Haven, CT 06520-8055 (D.C.M., J.C.); Department of Medicine, Division of Hepatology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY (B.E.F.); Department of Radiology, Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Ill (R.C.G., A.J.L., C.E.R.); and Department of Radiology, Interventional Radiology Service, Memorial Sloan-Kettering Cancer Center, New York, NY (H.Y.)
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 156] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Zaccherini G, Tufoni M, Bernardi M. Albumin Administration is Efficacious in the Management of Patients with Cirrhosis: A Systematic Review of the Literature. Hepat Med 2020; 12:153-172. [PMID: 33149707 PMCID: PMC7602890 DOI: 10.2147/hmer.s264231] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/18/2020] [Indexed: 12/15/2022] Open
Abstract
The use of albumin in patients with cirrhosis has been extensively discussed over recent years. Current treatment approaches depend on targeting related complications, aiming to treat and/or prevent circulatory dysfunction, bacterial infections and multi-organ failure. Albumin has been shown to prolong survival and reduce complications in patients with cirrhosis. This review aims to ascertain whether the use of albumin is justified in patients with cirrhosis. A systematic review of randomized controlled trials (RCTs) and meta-analyses evaluating albumin use in patients with cirrhosis published between 1985 and February 2020 was conducted; the quality and risk of bias of the included studies were assessed. In total, 45 RCTs and 10 meta-analyses were included. Based on the included evidence, albumin is superior at preventing and controlling the incidence of cirrhosis complications vs other plasma expanders. Recent studies reported that long-term albumin administration to patients with decompensated cirrhosis improves survival with a 38% reduction in the mortality hazard ratio compared with standard medical treatment alone. Albumin infusions are justified for routine use in patients with cirrhosis, and the use of albumin either alone or in combination with other treatments leads to clinical benefits. Long-term administration of albumin should be considered in some patients.
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Affiliation(s)
- Giacomo Zaccherini
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna 40138, Italy
| | - Manuel Tufoni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna 40138, Italy
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, Bologna 40138, Italy
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12
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Abstract
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.
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Affiliation(s)
- David Melia
- Whipps Cross University Hospital, London, UK
| | - Benjamin Post
- Department of Bioengineering and Department of Computing, Imperial College, London, UK
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13
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Alsebaey A, Rewisha E, Waked I. Paracentesis-induced circulatory dysfunction: are there albumin alternatives? EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00047-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Abstract
Background
Ascites is one of the main complications of advanced liver cirrhosis. It is defined as a pathological accumulation if free fluid in the peritoneal cavity.
Main body of the abstract
Ascites is a sign of decompensation in patients with liver cirrhosis and is associated with decreased survival. Ascites is associated with bad cosmetic figure and poor quality of life. Ascites is a predisposing factor for developing hydrothorax, hernias, diastolic dysfunction, spontaneous bacterial peritonitis, and renal impairment especially hepatorenal syndrome. The main treatment is salt restriction and diuretics. By the time the patient become non-responder and develop tense ascites, abdominal large volume paracentesis is the treatment of choice. Its advantages are rapid, cheap, and 1 day hospitalization. The main drawback is the development of paracentesis-induced circulatory dysfunction (PICD) if no volume expanding drugs are used. PICD is associated with dilutional hyponatremia, renal impairment, so it is considered the silent killer. Albumin infusion is the standard preventive measure but since costly to other alternatives such as colloids, vasoconstrictors or lowering the standard doses of the albumin was studied and is promising.
Conclusions
This review summarized the effectiveness of other alternative drugs.
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Kulkarni AV, Kumar P, Singh S, Sharma M, Talukdar R, Murthy VH, Singh V, Reddy ND, Rao NP. Prevention of paracentesis‐induced circulatory dysfunction—A systematic review and network meta‐analysis. ACTA ACUST UNITED AC 2020. [DOI: 10.1002/ygh2.395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Anand V. Kulkarni
- Department of Hepatology Asian Institute of Gastroenterology Hyderabad India
| | - Pramod Kumar
- Department of Hepatology Asian Institute of Gastroenterology Hyderabad India
| | - Siddharth Singh
- Department of Gastroenterology, and Division of Biomedical Informatics University of California San Diego La Jolla CA USA
| | - Mithun Sharma
- Department of Hepatology Asian Institute of Gastroenterology Hyderabad India
| | - Rupjyoti Talukdar
- Department of Gastroenterology Asian Institute of Gastroenterology Hyderabad India
| | | | | | - Nageshwar D Reddy
- Department of Gastroenterology Asian Institute of Gastroenterology Hyderabad India
| | - Nagaraja Padaki Rao
- Department of Hepatology Asian Institute of Gastroenterology Hyderabad India
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15
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Alsebaey A, Rewisha E, Waked I. High efficacy of low-dose albumin infusion in the prevention of paracentesis-induced circulatory dysfunction. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-0024-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
Large-volume paracentesis (LVP) is a main pillar in treating patients with tense ascites. Without plasma expanders use, paracentesis-induced circulatory dysfunction (PICD) is a common complication with decreased survival. The aim was to compare low-dose albumin (2 g/L ascitic fluid removed n = 85) with standard-dose albumin (6 g/L ascitic fluid removed, n = 25) for prevention of PICD. Liver function tests, urea, creatinine, CBC, and abdominal ultrasonography were done. Plasma renin activity (PRA) was measured at baseline and on the 6th day post-LVP. The delta change (Δ) = day 6 variable minus baseline variable value. PICD was defined as increase in PRA of > 50% of the baseline value.
Results
Patients in low-dose albumin group were mainly Child B compared with Child C (85.9% vs. 52%; p = 0.001), underwent less paracentesis volume (9.78 ± 3.56 vs. 12.52 ± 3.6 L; p = 0.001), but had higher baseline PRA (859.62 ± 1151.34 vs. 165.93 ± 95.34 pg/mL; p = 0.001). In both groups, the PRA increased at day 6 compared with the baseline (1141.57 ± 1433.01 vs. 859.62 ± 1151.34 pg/mL; p = 0.01) and (192.21 ± 80.99 vs. 165.93 ± 95.34 pg/mL; p = 0.01) respectively. Both groups were comparable for Δ PRA (281.95 ± 851.4 vs. 26.28 ± 30.2 pg/mL; p = 0.102) and PRA percent increase (10.97 ± 30.77 vs. 12.57 ± 14.87; p = 0.844). They had comparable PICD incidence (24.7% vs. 12%; p = 0.27). Females were more liable for PICD occurrence than males (OR 2.91, 95% CI 1.125–7.547, p = 0.028) and so Child B patients than Child C (OR 8.4, 95% CI 1.072–65.767, p = 0.043).
Conclusion
Low-dose albumin infusion is comparable to the standard-dose albumin for the prevention of PICD.
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16
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Kulkarni AV, Kumar P, Sharma M, Sowmya TR, Talukdar R, Rao PN, Reddy DN. Pathophysiology and Prevention of Paracentesis-induced Circulatory Dysfunction: A Concise Review. J Clin Transl Hepatol 2020; 8:42-48. [PMID: 32274344 PMCID: PMC7132018 DOI: 10.14218/jcth.2019.00048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/16/2020] [Accepted: 02/23/2020] [Indexed: 12/16/2022] Open
Abstract
Annually, 10% of cirrhotic patients with ascites develop refractory ascites for which large-volume paracentesis (LVP) is a frequently used therapeutic procedure. LVP, although a safe method, is associated with circulatory dysfunction in a significant percentage of patients, which is termed paracentesis-induced circulatory dysfunction (PICD). PICD results in faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival. PICD is diagnosed through laboratory results, with increases of >50% of baseline plasma renin activity to a value ≥4 ng/mL/h on the fifth to sixth day after paracentesis. In this review, we discuss the pathophysiology and prevention of PICD.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
- Correspondence to: Anand V Kulkarni, Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India. E-mail: ,
| | - Pramod Kumar
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - T R Sowmya
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Padaki Nagaraj Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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17
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Benmassaoud A, Freeman SC, Roccarina D, Plaz Torres MC, Sutton AJ, Cooper NJ, Iogna Prat L, Cowlin M, Milne EJ, Hawkins N, Davidson BR, Pavlov CS, Thorburn D, Tsochatzis E, Gurusamy KS. Treatment for ascites in adults with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2020; 1:CD013123. [PMID: 31978257 PMCID: PMC6984622 DOI: 10.1002/14651858.cd013123.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Approximately 20% of people with cirrhosis develop ascites. Several different treatments are available; including, among others, paracentesis plus fluid replacement, transjugular intrahepatic portosystemic shunts, aldosterone antagonists, and loop diuretics. However, there is uncertainty surrounding their relative efficacy. OBJECTIVES To compare the benefits and harms of different treatments for ascites in people with decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for ascites according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until May 2019 to identify randomised clinical trials in people with cirrhosis and ascites. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and ascites. We excluded randomised clinical trials in which participants had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 49 randomised clinical trials (3521 participants) in the review. Forty-two trials (2870 participants) were included in one or more outcomes in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies, without other features of decompensation, having mainly grade 3 (severe), recurrent, or refractory ascites. The follow-up in the trials ranged from 0.1 to 84 months. All the trials were at high risk of bias, and the overall certainty of evidence was low or very low. Approximately 36.8% of participants who received paracentesis plus fluid replacement (reference group, the current standard treatment) died within 11 months. There was no evidence of differences in mortality, adverse events, or liver transplantation in people receiving different interventions compared to paracentesis plus fluid replacement (very low-certainty evidence). Resolution of ascites at maximal follow-up was higher with transjugular intrahepatic portosystemic shunt (HR 9.44; 95% CrI 1.93 to 62.68) and adding aldosterone antagonists to paracentesis plus fluid replacement (HR 30.63; 95% CrI 5.06 to 692.98) compared to paracentesis plus fluid replacement (very low-certainty evidence). Aldosterone antagonists plus loop diuretics had a higher rate of other decompensation events such as hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding compared to paracentesis plus fluid replacement (rate ratio 2.04; 95% CrI 1.37 to 3.10) (very low-certainty evidence). None of the trials using paracentesis plus fluid replacement reported health-related quality of life or symptomatic recovery from ascites. FUNDING the source of funding for four trials were industries which would benefit from the results of the study; 24 trials received no additional funding or were funded by neutral organisations; and the source of funding for the remaining 21 trials was unclear. AUTHORS' CONCLUSIONS Based on very low-certainty evidence, there is considerable uncertainty about whether interventions for ascites in people with decompensated liver cirrhosis decrease mortality, adverse events, or liver transplantation compared to paracentesis plus fluid replacement in people with decompensated liver cirrhosis and ascites. Based on very low-certainty evidence, transjugular intrahepatic portosystemic shunt and adding aldosterone antagonists to paracentesis plus fluid replacement may increase the resolution of ascites compared to paracentesis plus fluid replacement. Based on very low-certainty evidence, aldosterone antagonists plus loop diuretics may increase the decompensation rate compared to paracentesis plus fluid replacement.
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Affiliation(s)
- Amine Benmassaoud
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Suzanne C Freeman
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Davide Roccarina
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | | | - Alex J Sutton
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Nicola J Cooper
- University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
| | - Laura Iogna Prat
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | | | | | - Neil Hawkins
- University of GlasgowHEHTAUniversity Ave Glasgow G12 8QQGlasgowUK
| | - Brian R Davidson
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2QG
| | - Chavdar S Pavlov
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
| | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentreLondonUK
| | - Kurinchi Selvan Gurusamy
- University College LondonDivision of Surgery and Interventional ScienceLondonUKNW3 2QG
- 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
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18
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Abstract
Ascites occurs in up to 70% of patients during the natural history of cirrhosis. Management of uncomplicated ascites includes sodium restriction and diuretic therapy, whereas that for refractory ascites (RA) is regular large-volume paracentesis with transjugular intrahepatic portosystemic shunt being offered in appropriate patients. Renal impairment occurs in up to 50% of patients with RA with type 1 hepatorenal syndrome (HRS) being most severe. Liver transplant remains the definitive treatment of eligible candidates with HRS, whereas combined liver and kidney transplant should be considered in patients requiring dialysis for more than 4 to 6 weeks or those with underlying chronic kidney disease.
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19
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Kasztelan-Szczerbinska B, Cichoz-Lach H. Refractory ascites-the contemporary view on pathogenesis and therapy. PeerJ 2019; 7:e7855. [PMID: 31637125 PMCID: PMC6798865 DOI: 10.7717/peerj.7855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 09/09/2019] [Indexed: 12/14/2022] Open
Abstract
Refractory ascites (RA) refers to ascites that cannot be mobilized or that has an early recurrence that cannot be prevented by medical therapy. Every year, 5–10% of patients with liver cirrhosis and with an accumulation of fluid in the peritoneal cavity develop RA while undergoing standard treatment (low sodium diet and diuretic dose up to 400 mg/day of spironolactone and 160 mg/day of furosemide). Liver cirrhosis accounts for marked alterations in the splanchnic and systemic hemodynamics, causing hypovolemia and arterial hypotension. The consequent activation of renin-angiotensin and sympathetic systems and increased renal sodium re-absorption occurs during the course of the disease. Cirrhotic patients with RA have poor prognoses and are at risk of developing serious complications. Different treatment options are available, but only liver transplantation may improve the survival of such patients.
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Affiliation(s)
| | - Halina Cichoz-Lach
- Department of Gastroenterology with Endoscopy Unit, Medical University of Lublin, Poland
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20
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Simonetti RG, Perricone G, Nikolova D, Bjelakovic G, Gluud C. Plasma expanders for people with cirrhosis and large ascites treated with abdominal paracentesis. Cochrane Database Syst Rev 2019; 6:CD004039. [PMID: 31251387 PMCID: PMC6598734 DOI: 10.1002/14651858.cd004039.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Plasma volume expanders are used in connection to paracentesis in people with cirrhosis to prevent reduction of effective plasma volume, which may trigger deleterious effect on haemodynamic balance, and increase morbidity and mortality. Albumin is considered the standard product against which no plasma expansion or other plasma expanders, e.g. other colloids (polygeline , dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol have been compared. However, the benefits and harms of these plasma expanders are not fully clear. OBJECTIVES To assess the benefits and harms of any plasma volume expanders such as albumin, other colloids (polygeline, dextrans, hydroxyethyl starch solutions, fresh frozen plasma), intravenous infusion of ascitic fluid, crystalloids, or mannitol versus no plasma volume expander or versus another plasma volume expander for paracentesis in people with cirrhosis and large ascites. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, CNKI, VIP, Wanfang, Science Citation Index Expanded, and Conference Proceedings Citation Index until January 2019. Furthermore, we searched FDA, EMA, WHO (last search January 2019), www.clinicaltrials.gov/, and www.controlled-trials.com/ for ongoing trials. SELECTION CRITERIA Randomised clinical trials, no matter their design or year of publication, publication status, and language, assessing the use of any type of plasma expander versus placebo, no intervention, or a different plasma expander in connection with paracentesis for ascites in people with cirrhosis. We considered quasi-randomised, retrieved with the searches for randomised clinical trials only, for reports on harms. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We calculated the risk ratio (RR) or mean difference (MD) using the fixed-effect model and the random-effects model meta-analyses, based on the intention-to-treat principle, whenever possible. If the fixed-effect and random-effects models showed different results, then we made our conclusions based on the analysis with the highest P value (the more conservative result). We assessed risks of bias of the individual trials using predefined bias risk domains. We assessed the certainty of the evidence at an outcome level, using GRADE, and constructed 'Summary of Findings' tables for seven of our review outcomes. MAIN RESULTS We identified 27 randomised clinical trials for inclusion in this review (24 published as full-text articles and 3 as abstracts). Five of the trials, with 271 participants, assessed plasma expanders (albumin in four trials and ascitic fluid in one trial) versus no plasma expander. The remaining 22 trials, with 1321 participants, assessed one type of plasma expander, i.e. dextran, hydroxyethyl starch, polygeline, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus another type of plasma expander, i.e. albumin in 20 of these trials and polygeline in one trial. Twenty-five trials provided data for quantitative meta-analysis. According to the Child-Pugh classification, most participants were at an intermediate to advanced stage of liver disease in the absence of hepatocellular carcinoma, recent gastrointestinal bleeding, infections, and hepatic encephalopathy. All trials were assessed as at overall high risk of bias. Ten trials seemed not to have been funded by industry; twelve trials were considered unclear about funding; and five trials were considered funded by industry or a for-profit institution.We found no evidence of a difference in effect between plasma expansion versus no plasma expansion on mortality (RR 0.52, 95% CI 0.06 to 4.83; 248 participants; 4 trials; very low certainty); renal impairment (RR 0.32, 95% CI 0.02 to 5.88; 181 participants; 4 trials; very low certainty); other liver-related complications (RR 1.61, 95% CI 0.79 to 3.27; 248 participants; 4 trials; very low certainty); and non-serious adverse events (RR 1.04, 95% CI 0.32 to 3.40; 158 participants; 3 trials; very low certainty). Two of the trials stated that no serious adverse events occurred while the remaining trials did not report on this outcome. No trial reported data on health-related quality of life.We found no evidence of a difference in effect between experimental plasma expanders versus albumin on mortality (RR 1.03, 95% CI 0.82 to 1.30; 1014 participants; 14 trials; very low certainty); serious adverse events (RR 0.89, 95% CI 0.10 to 8.30; 118 participants; 2 trials; very low certainty); renal impairment (RR 1.17, 95% CI 0.71 to 1.91; 1107 participants; 17 trials; very low certainty); other liver-related complications (RR 1.10, 95% CI 0.82 to 1.48; 1083 participants; 16 trials; very low certainty); and non-serious adverse events (RR 1.37, 95% CI 0.66 to 2.85; 977 participants; 14 trials; very low certainty). We found no data on heath-related quality of life and refractory ascites. AUTHORS' CONCLUSIONS Our systematic review and meta-analysis did not find any benefits or harms of plasma expanders versus no plasma expander or of one plasma expander such as polygeline, dextrans, hydroxyethyl starch, intravenous infusion of ascitic fluid, crystalloids, or mannitol versus albumin on primary or secondary outcomes. The data originated from few, small, mostly short-term trials at high risks of systematic errors (bias) and high risks of random errors (play of chance). GRADE assessments concluded that the evidence was of very low certainty. Therefore, we can neither demonstrate or discard any benefit of plasma expansion versus no plasma expansion, and differences between one plasma expander versus another plasma expander.Larger trials at low risks of bias are needed to assess the role of plasma expanders in connection with paracentesis. Such trials should be conducted according to the SPIRIT guidelines and reported according to the CONSORT guidelines.
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Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato‐Biliary GroupBlegdamsvej 9, 7811CopenhagenDenmark2100
| | - Giovanni Perricone
- Azienda Socio‐Sanitaria Territoriale Grande Ospedale Metropolitano NiguardaS.C. Epatologia e GastroenterologiaPiazza Ospedale Maggiore, 3MilanItaly20162
- UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free HospitalLiver Failure GroupLondonUK
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Goran Bjelakovic
- Medical Faculty, University of NisDepartment of Internal MedicineZorana Djindjica 81NisSerbia18000
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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21
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Neong SF, Adebayo D, Wong F. An update on the pathogenesis and clinical management of cirrhosis with refractory ascites. Expert Rev Gastroenterol Hepatol 2019; 13:293-305. [PMID: 30791777 DOI: 10.1080/17474124.2018.1555469] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Ascites commonly complicates cirrhosis, becoming refractory to treatment with diuretics and sodium restriction in approximately 10% of patients. Pathogenesis of refractory ascites (RA) is multifactorial, the common final pathway being renal hypoperfusion and avid sodium retention. Refractory ascites has a negative prognostic implication in the natural history of cirrhosis. Management of RA include sodium restriction and regular large volume paracentesis (LVP) with albumin infusions, preventing paracentesis-induced circulatory dysfunction. In appropriate setting, transjugular intrahepatic porto-systemic shunt (TIPS) can be considered. Ascites clearance with TIPS can lead to nutritional improvement, avoiding sarcopenia. Liver transplantation (LT) remains the definitive treatment for eligible candidates. Areas covered: Our review summarizes current updates on pathogenesis and clinical management of RA including potential future therapeutic options such as the automated slow-flow ascites pump, chronic outpatient albumin infusion and cell-free and concentrated ascites reinfusion therapy. Expert commentary: Standard of care in patients with RA include LVP with albumin replacement and prompt referral for LT where indicated. Other novel therapeutic options on the horizon include automated low-flow ascites pump and cell-free, concentrated albumin reinfusion therapy.
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Affiliation(s)
- Shuet Fong Neong
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| | - Danielle Adebayo
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
| | - Florence Wong
- a Division of Gastroenterology, Department of Medicine, Toronto General Hospital , University of Toronto , Toronto , Ontario , Canada
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22
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Marciano S, Díaz JM, Dirchwolf M, Gadano A. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies. Hepat Med 2019; 11:13-22. [PMID: 30666172 PMCID: PMC6336019 DOI: 10.2147/hmer.s164250] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.
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Affiliation(s)
- Sebastián Marciano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Juan Manuel Díaz
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
| | - Melisa Dirchwolf
- Hepatology Unit, Hospital Privado de Rosario, Santa Fe, Argentina
| | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
- Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina,
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23
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Abstract
Ascites, a common complication of liver cirrhosis, eventually becomes refractory to diuretic therapy and sodium restriction in ∼10% of patients. Multiple pathogenetic factors are involved in the development of refractory ascites, which ultimately lead to renal hypoperfusion and avid sodium retention. Therefore, renal dysfunction commonly accompanies refractory ascites. Management includes continuation of sodium restriction, which needs frequent reviews for adherence; and regular large volume paracentesis of 5 L or more with albumin infusions to prevent the development of paracentesis-induced circulatory dysfunction. In the appropriate patients with reasonable liver reserve, the insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS) can be considered, especially if the patient is relatively young and has no previous hepatic encephalopathy or anatomical contraindications, and no past history of renal or cardiopulmonary disease. Response to TIPS with ascites clearance can lead to nutritional improvement. Devices such as an automated low-flow ascites pump may be available in the future for ascites treatment. Patients with refractory ascites and poor liver function and/or renal dysfunction, should be referred for liver transplant, as this will eliminate the portal hypertension and liver dysfunction. Renal dysfunction prior to liver transplant largely improves after transplant without affecting post-transplant survival.
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Affiliation(s)
- Danielle Adebayo
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| | - Shuet Fong Neong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada. These authors contributed equally: Danielle Adebayo, Shuet Fong Neong
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KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018; 24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
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Abstract
Ascites is the most common cause of decompensation in cirrhosis, and 5% to 10% of patients with compensated cirrhosis develop ascites each year. The main factor of ascites formation is renal sodium retention due to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system by the reduced effective volume secondary to splanchnic arterial vasodilation. Diagnostic paracentesis is indicated in all patients with a new onset of grade 2 or 3 ascites and in those admitted to hospital for any complication of cirrhosis. A serum-ascites albumin gradient of ≥1.1 g/dL indicates portal hypertension with an accuracy of approximately 97%. Sodium restriction, diuretics, and large volume paracentesis are the mainstay of treatment in grade 1 to 3 ascites. The refractoriness of ascites is associated with a poor prognosis with a median survival of approximately six months. Repeated large volume paracentesis plus albumin is the first line treatment, and liver transplantation is recommended in patients with refractory ascites. A careful selection of patients is also important to obtain the beneficial effects of transjugular intrahepatic portosystemic shunts in refractory ascites. This review details the recent diagnosis and treatment of cirrhotic ascites.
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Affiliation(s)
- Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1499] [Impact Index Per Article: 249.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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Albumin Use in Patients With Cirrhosis in France: Results of the "ALBU-LIVE" Survey: A Case for Better EASL Guidelines Diffusion and/or Revision. J Clin Gastroenterol 2017; 51:831-838. [PMID: 28787354 DOI: 10.1097/mcg.0000000000000735] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The use of human albumin for the management of cirrhosis has increased. Recommendations have been published for therapeutic paracentesis (TP), spontaneous bacterial peritonitis (SBP), and type 1 hepatorenal syndrome (HRS). The goal of this survey was to assess the prescription practices of French hepatogastroenterologists. METHODS All hepatogastroenterologists were contacted. The questionnaire evaluated (1) the use of albumin in validated indications and (2) the prescription of albumin for nonvalidated clinical situations. RESULTS Responses were analyzed from 451 (50.1%) practitioners. The mean age was 40 years (range, 24 to 67 y). Physicians practiced in a university hospital (47.7%) or a general hospital (45.8%). There were 56.7% senior practitioners. Overall 99.6% of the practitioners compensated for TP. Albumin was used by 87.8% of the physicians, with a fixed dose being used by 84.6%. For SBP, 94% of the physicians used albumin concomitantly with antibiotics. The recommended protocol was followed by 56.2% of the practitioners: more often by senior university hospital practitioners than by senior general hospital practitioners (P=0.015). About 66.5% used albumin infusion for the diagnosis of HRS: used more often by senior university hospital practitioners (P=0.0006). Albumin was used concomitantly with vasopressor treatment by 84%; the dose and the duration varied considerably. About 23.5% used albumin for severe bacterial infection, 47.9% for severe hyponatremia, 43.9% for severe hypoalbuminemia, and 65.9% for hydrothorax. CONCLUSIONS In this large French survey, albumin is only prescribed in accordance with recommendations for TP. The schedule for SBP is followed by only 56% of the practitioners. The use of albumin for HRS is not adapted to recommendations, which are not well known, suggesting that they should be more diffused.
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Kütting F, Schubert J, Franklin J, Bowe A, Hoffmann V, Demir M, Pelc A, Nierhoff D, Töx U, Steffen HM. Insufficient evidence of benefit regarding mortality due to albumin substitution in HCC-free cirrhotic patients undergoing large volume paracentesis. J Gastroenterol Hepatol 2017; 32:327-338. [PMID: 27149296 DOI: 10.1111/jgh.13421] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Fabian Kütting
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Jens Schubert
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Jeremy Franklin
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Andrea Bowe
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Vera Hoffmann
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Muenevver Demir
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Agnes Pelc
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Dirk Nierhoff
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Ulrich Töx
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Hans-Michael Steffen
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
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AISF-SIMTI position paper: the appropriate use of albumin in patients with liver cirrhosis. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:8-22. [PMID: 26820615 DOI: 10.2450/2016.0294-15] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Cross-Sectional Guidelines for Therapy with Blood Components and Plasma Derivatives: Chapter 5 Human Albumin - Revised. Transfus Med Hemother 2016; 43:223-32. [PMID: 27403094 PMCID: PMC4924448 DOI: 10.1159/000446043] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/12/2016] [Indexed: 12/21/2022] Open
Abstract
Chapter 5 'Human Albumin' that was suspended on January 10, 2011 has been completed and updated in the present version.
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Nadim MK, Durand F, Kellum JA, Levitsky J, O'Leary JG, Karvellas CJ, Bajaj JS, Davenport A, Jalan R, Angeli P, Caldwell SH, Fernández J, Francoz C, Garcia-Tsao G, Ginès P, Ison MG, Kramer DJ, Mehta RL, Moreau R, Mulligan D, Olson JC, Pomfret EA, Senzolo M, Steadman RH, Subramanian RM, Vincent JL, Genyk YS. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. J Hepatol 2016; 64:717-35. [PMID: 26519602 DOI: 10.1016/j.jhep.2015.10.019] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/30/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Constantine J Karvellas
- Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University, McGuire VA Medical Center, Richmond, VA, USA
| | - Andrew Davenport
- University College London Center for Nephrology, Royal Free Hospital, University College London Medical School, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Javier Fernández
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Centro d'investigación biomedical en red de enfermedades hepáticas y digestivas, Barcelona, Spain
| | - Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer, Centro d'investigación biomedical en red de enfermedades hepáticas y digestivas, Barcelona, Spain
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David J Kramer
- Aurora Critical Care Service, Aurora Health Care, Milwaukee, WI, USA
| | - Ravindra L Mehta
- Division of Nephrology, University of California San Diego, San Diego, CA, USA
| | - Richard Moreau
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris, INSERM U1149, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
| | - David Mulligan
- Section of Transplantation and Immunology, Department of Surgery, Yale-New Haven Hospital Transplantation Center, Yale School of Medicine, New Haven, CT, USA
| | - Jody C Olson
- Division of Hepatology, University of Kansas Hospital, Kansas City, KS, USA
| | - Elizabeth A Pomfret
- Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padua, Italy
| | - Randolph H Steadman
- Department of Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA
| | - Ram M Subramanian
- Divisions of Gastroenterology and Pulmonary & Critical Care Medicine, Emory University Hospital, Atlanta, GA, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Yuri S Genyk
- Division of Hepatobiliary Surgery and Abdominal Organ Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis. Dig Liver Dis 2016; 48:4-15. [PMID: 26802734 DOI: 10.1016/j.dld.2015.11.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 11/14/2015] [Indexed: 12/11/2022]
Abstract
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.
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Solà E, Solé C, Ginès P. Management of uninfected and infected ascites in cirrhosis. Liver Int 2016; 36 Suppl 1:109-15. [PMID: 26725907 DOI: 10.1111/liv.13015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 02/06/2023]
Abstract
Ascites is the most frequent complication of patients with cirrhosis. Ascites is related to increased renal sodium retention as a result of increased activity of the renin-angiotensin-aldosterone system in response to marked vasodilation of the splanchnic circulation. Management of uncomplicated ascites is based on a low-sodium diet and diuretics. However, approximately 10% of patients develop refractory ascites during follow-up, which is associated with a poor prognosis. The treatment of choice in patients with refractory ascites is large-volume paracentesis associated with intravenous albumin. Moreover, patients who develop refractory ascites should be considered as candidates for liver transplantation. Patients with ascites are all at risk of developing spontaneous bacterial peritonitis (SBP). SBP is a common infection in patients with cirrhosis with a risk of mortality of 20%. Empirical antibiotics are the treatment of choice in patients with SBP but differ depending on the acquisition site of infection, because nosocomial infections have a higher risk of being caused by multiresistant bacteria. In addition to antibiotic treatment, all patients with SBP should also receive intravenous albumin. This review summarizes the management of uninfected ascites and SBP in cirrhosis.
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Affiliation(s)
- Elsa Solà
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Reina Sofía de Investigación Nefrológica (IRSIN)
| | - Cristina Solé
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Reina Sofía de Investigación Nefrológica (IRSIN)
| | - Pere Ginès
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto Reina Sofía de Investigación Nefrológica (IRSIN)
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Elsabaawy MM, Abdelhamid SR, Alsebaey A, Abdelsamee E, Obada MA, Salman TA, Rewisha E. The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction. Clin Mol Hepatol 2015; 21:365-71. [PMID: 26770925 PMCID: PMC4712164 DOI: 10.3350/cmh.2015.21.4.365] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 08/29/2015] [Accepted: 09/04/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Maha Mohammad Elsabaawy
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | | | - Ayman Alsebaey
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Eman Abdelsamee
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Manar Abdelaal Obada
- Department of Clinical Biochemistry, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Tary Abdelhamid Salman
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Eman Rewisha
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
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35
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Affiliation(s)
- Maria Bashyam
- Specialist Registrar in Gastroenterology in the Department of Gastroenterology, Chelsea & Westminster Hospital, London SW10 9NH
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36
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Elsabaawy MM, Abdelhamid SR, Alsebaey A, Abdelsamee E, Obada MA, Salman TA, Rewisha E. The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction. Clin Mol Hepatol 2015. [DOI: https://doi.org/10.3350/cmh.2015.21.4.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Maha Mohammad Elsabaawy
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | | | - Ayman Alsebaey
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Eman Abdelsamee
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Manar Abdelaal Obada
- Department of Clinical Biochemistry, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Tary Abdelhamid Salman
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Eman Rewisha
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
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37
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Elsabaawy MM, Abdelhamid SR, Alsebaey A, Abdelsamee E, Obada MA, Salman TA, Rewisha E. The impact of paracentesis flow rate in patients with liver cirrhosis on the development of paracentesis induced circulatory dysfunction. Clin Mol Hepatol 2015. [DOI: https:/doi.org/10.3350/cmh.2015.21.4.365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Maha Mohammad Elsabaawy
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | | | - Ayman Alsebaey
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Eman Abdelsamee
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Manar Abdelaal Obada
- Department of Clinical Biochemistry, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Tary Abdelhamid Salman
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
| | - Eman Rewisha
- Department of Hepatology, National Liver Institute, Menoufia University, Shebeen El-Kom, Egypt
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Bernardi M, Ricci CS, Zaccherini G. Role of human albumin in the management of complications of liver cirrhosis. J Clin Exp Hepatol 2014; 4:302-11. [PMID: 25755577 PMCID: PMC4298636 DOI: 10.1016/j.jceh.2014.08.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/27/2014] [Indexed: 02/09/2023] Open
Abstract
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.
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Key Words
- ACB, albumin cobalt binding
- ACLF, acute-on-chronic liver failure
- EASL, European Association for the Study of the Liver
- EPR, electron paramagnetic resonance
- HE, hepatic encephalopathy
- HPLC, high performance liquid chromatography
- HRS, hepatorenal syndrome
- IMA, ischemia-modified albumin
- MALDI-TOF, Matrix-Assisted Laser Desorption/Ionization with Time of flight technique
- MARS, Molecular Adsorbent Recirculating Systems
- MELD, model for end stage liver disease
- NO, nitric oxide
- PPCD, post-paracentesis circulatory dysfunction
- RAAS, renin-angiotensin-aldosteron axis
- ROS, reactive oxygen species
- SBP, spontaneous bacterial peritonitis
- SNS, sympathetic nervous system
- albumin
- ascites
- bacterial infections
- cirrhosis of the liver
- non-oncotic properties of albumin
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Affiliation(s)
- Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Italy
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Kwok CS, Krupa L, Mahtani A, Kaye D, Rushbrook SM, Phillips MG, Gelson W. Albumin reduces paracentesis-induced circulatory dysfunction and reduces death and renal impairment among patients with cirrhosis and infection: a systematic review and meta-analysis. BIOMED RESEARCH INTERNATIONAL 2013; 2013:295153. [PMID: 24222902 PMCID: PMC3816020 DOI: 10.1155/2013/295153] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/31/2013] [Accepted: 08/05/2013] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Chun Shing Kwok
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Lukasz Krupa
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Ash Mahtani
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Duncan Kaye
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Simon M. Rushbrook
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - Martin G. Phillips
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
| | - William Gelson
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK
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How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists. J Hepatol 2013; 59:257-64. [PMID: 23523582 DOI: 10.1016/j.jhep.2013.03.010] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 03/06/2013] [Accepted: 03/12/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The development of ascites in patients with cirrhosis is associated with a high rate of health care utilization. New models of specialized caregiving support are necessary to optimize its management. The aim of the study was to evaluate the efficacy and financial sustainability of the "Care management check-up" as a new model of specialized caregiving support based on a series of diagnostic facilities performed in real time and on the integrated activity of consultant hepatologists at the hospital unit for outpatients, dedicated nurses, physicians in training and primary physicians, compared to standard care in outpatients with cirrhosis and ascites. METHODS 100 cirrhotic patients admitted to our hospital were allocated, after discharge, to the "Care management check-up" group (group 1), or to the "Standard outpatient care" group (group 2), and followed prospectively as outpatients up to death or for at least 12 months. Patients of the two groups could also access to a "Day hospital" when an invasive procedure was required. In group 1, the "Care management check-up" and the "Day hospital" taken together defined the "Care management program". RESULTS Twelve-month mortality was higher in group 2 than in group 1 (45.7% vs. 23.1%, p<0.025). The rate of 30-day readmission was also higher in group 2 (42.4% vs. 15.4%, p<0.01). The global cost attributable to the management per patient-month of life was lower (1479.19 ± 2184.43 €) in group 1 than (2816.13 ± 3893.03 €) in group 2 (p<0.05). CONCLUSIONS The study suggests that this new model of specialized caregiving reduces 12-month mortality in patients with cirrhosis and ascites as well as the global health care costs for their management.
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Bernardi M, Maggioli C, Zaccherini G. Human albumin in the management of complications of liver cirrhosis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:211. [PMID: 22429536 PMCID: PMC3681351 DOI: 10.1186/cc11218] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Mauro Bernardi
- Department of Anesthesia and Intensive Care, Cattinara Hospital, Strada di Fiume 447, 34149 Trieste, Italy.
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42
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Abstract
Hypoalbuminemia is frequently observed in hospitalized patients and it can be associated with several different diseases, including cirrhosis, malnutrition, nephrotic syndrome and sepsis. Regardless of its cause, hypoalbuminemia has a strong predictive value on mortality and morbidity. Over the years, the rationale for the use of albumin has been extensively debated and the indications for human serum albumin supplementation have changed. As the knowledge of the pathophysiological mechanisms of the pertinent diseases has increased, the indications for intravenous albumin supplementation have progressively decreased. The purpose of this brief article is to review the causes of hypoalbuminemia and the current indications for intravenous administration of albumin. Based on the available data and considering the costs, albumin supplementation should be limited to well-defined clinical scenarios and to include patients with cirrhosis and spontaneous bacterial peritonitis, patients with cirrhosis undergoing large volume paracentesis, the treatment of type 1 hepatorenal syndrome, fluid resuscitation of patients with sepsis, and therapeutic plasmapheresis with exchange of large volumes of plasma. While albumin supplementation is accepted also in other clinical situations such as burns, nephrotic syndrome, hemorrhagic shock and prevention of hepatorenal syndrome, within these contexts it does not represent a first-choice treatment nor is its use supported by widely accepted guidelines.
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Affiliation(s)
- Angelo Gatta
- Department of Medicine, University of Padova, Padua, Italy.
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Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology 2012; 55:1172-81. [PMID: 22095893 DOI: 10.1002/hep.24786] [Citation(s) in RCA: 215] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Albumin infusion reduces the incidence of postparacentesis circulatory dysfunction among patients with cirrhosis and tense ascites, as compared with no treatment. Treatment alternatives to albumin, such as artificial colloids and vasoconstrictors, have been widely investigated. The aim of this meta-analysis was to determine whether morbidity and mortality differ between patients receiving albumin versus alternative treatments. The meta-analysis included randomized trials evaluating albumin infusion in patients with tense ascites. Primary endpoints were postparacentesis circulatory dysfunction, hyponatremia, and mortality. Eligible trials were sought by multiple methods, including computer searches of bibliographic and abstract databases and the Cochrane Library. Results were quantitatively combined under a fixed-effects model. Seventeen trials with 1,225 total patients were included. There was no evidence of heterogeneity or publication bias. Compared with alternative treatments, albumin reduced the incidence of postparacentesis circulatory dysfunction (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.27-0.55). Significant reductions in that complication by albumin were also shown in subgroup analyses versus each of the other volume expanders tested (e.g., dextran, gelatin, hydroxyethyl starch, and hypertonic saline). The occurrence of hyponatremia was also decreased by albumin, compared with alternative treatments (OR, 0.58; 95% CI, 0.39-0.87). In addition, mortality was lower in patients receiving albumin than alternative treatments (OR, 0.64; 95% CI, 0.41-0.98). CONCLUSIONS This meta-analysis provides evidence that albumin reduces morbidity and mortality among patients with tense ascites undergoing large-volume paracentesis, as compared with alternative treatments investigated thus far.
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Affiliation(s)
- Mauro Bernardi
- Dipartimento di Medicina Clinica, Alma Mater Studiorum-Università di Bologna, Semeiotica Medica-Policlinico S. Orsola-Malpighi, Bologna, Italy.
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Suk KT, Baik SK, Yoon JH, Cheong JY, Paik YH, Lee CH, Kim YS, Lee JW, Kim DJ, Cho SW, Hwang SG, Sohn JH, Kim MY, Kim YB, Kim JG, Cho YK, Choi MS, Kim HJ, Lee HW, Kim SU, Kim JK, Choi JY, Jun DW, Tak WY, Lee BS, Jang BK, Chung WJ, Kim HS, Jang JY, Jeong SW, Kim SG, Kwon OS, Jung YK, Choe WH, Lee JS, Kim IH, Shim JJ, Cheon GJ, Bae SH, Seo YS, Choi DH, Jang SJ. Revision and update on clinical practice guideline for liver cirrhosis. THE KOREAN JOURNAL OF HEPATOLOGY 2012; 18:1-21. [PMID: 22511898 PMCID: PMC3326994 DOI: 10.3350/kjhep.2012.18.1.1] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 03/05/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Soon Koo Baik
- Department of Internal Medicine and Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Hwan Yoon
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Youn Cheong
- Department of Internal Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yong Han Paik
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu College of Medicine, Daegu, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jin Woo Lee
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung Won Cho
- Department of Internal Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Seong Gyu Hwang
- Department of Internal Medicine, Cha University College of Medicine, Seongnam, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Moon Young Kim
- Department of Internal Medicine and Cell Therapy and Tissue Engineering Center, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Bae Kim
- Department of Pathology, Ajou University College of Medicine, Suwon, Korea
| | - Jae Geun Kim
- Department of Radiology, Ajou University College of Medicine, Suwon, Korea
| | - Yong Kyun Cho
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Hyung Joon Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Woong Lee
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ja Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Young Choi
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Korea
| | - Won Young Tak
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University College of Medicine, Daegu, Korea
| | - Hong Soo Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Cheonan, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Hospital Seoul, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Hospital Bucheon, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Oh Sang Kwon
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University College of Medicine, Seoul, Korea
| | - June Sung Lee
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Korea
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University College of Medicine, Jeonju, Korea
| | - Jae Jun Shim
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Ulsan University College of Medicine, Gangneung, Korea
| | - Si Hyun Bae
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Hee Choi
- Department of Internal Medicine, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Se Jin Jang
- Department of Preventive Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Abstract
Ascites is a common complication of liver cirrhosis associated with a poor prognosis. The treatment of ascites requires dietary sodium restriction and the judicious use of distal and loop diuretics, sequential at an earlier stage of ascites, and a combination at a later stage of ascites. The diagnosis of refractory ascites requires the demonstration of diuretic non-responsiveness, despite dietary sodium restriction, or the presence of diuretic-related complications. Patients with refractory ascites require second-line treatments of repeat large-volume paracentesis (LVP) or the insertion of a transjugular intrahepatic portosystemic shunt (TIPS), and assessment for liver transplantation. Careful patient selection is paramount for TIPS to be successful as a treatment for ascites. Patients not suitable for TIPS insertion should receive LVP. The use of albumin as a volume expander is recommended for LVP of >5-6 L to prevent the development of circulatory dysfunction, although the clinical significance of post-paracentesis circulatory dysfunction is still debated. Significant mortality is still being observed in cirrhotic patients with ascites and relatively preserved liver and renal function, as indicated by a lower Model for End-Stage Liver Disease (MELD) score. It is proposed that patients with lower MELD scores and ascites should receive additional points in calculating their priority for liver transplantation. Potential new treatment options for ascites include the use of various vasoconstrictors, vasopressin V(2) receptor antagonists, or the insertion of a peritoneo-vesical shunt, all of which could possibly improve the management of ascites.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol 2011; 17:1237-48. [PMID: 21455322 PMCID: PMC3068258 DOI: 10.3748/wjg.v17.i10.1237] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 02/06/2023] Open
Abstract
Ascites is one of the major complications of liver cirrhosis and is associated with a poor prognosis. It is important to distinguish noncirrhotic from cirrhotic causes of ascites to guide therapy in patients with noncirrhotic ascites. Mild to moderate ascites is treated by salt restriction and diuretic therapy. The diuretic of choice is spironolactone. A combination treatment with furosemide might be necessary in patients who do not respond to spironolactone alone. Tense ascites is treated by paracentesis, followed by albumin infusion and diuretic therapy. Treatment options for refractory ascites include repeated paracentesis and transjugular intrahepatic portosystemic shunt placement in patients with a preserved liver function. Potential complications of ascites are spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS). SBP is diagnosed by an ascitic neutrophil count > 250 cells/mm3 and is treated with antibiotics. Patients who survive a first episode of SBP or with a low protein concentration in the ascitic fluid require an antibiotic prophylaxis. The prognosis of untreated HRS type 1 is grave. Treatment consists of a combination of terlipressin and albumin. Hemodialysis might serve in selected patients as a bridging therapy to liver transplantation. Liver transplantation should be considered in all patients with ascites and liver cirrhosis.
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Boldt J. [Guidelines on therapy with blood components and plasma derivatives: human albumin. Recommendations of the scientific advisory board of the Medical Council]. Anaesthesist 2010; 59:566-74. [PMID: 20490440 DOI: 10.1007/s00101-010-1734-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Human albumin (HA) is by far the most expensive option for volume replacement and correction of hypoalbuminemia but is still widely used. The value of HA in the clinical setting continues to be controversial and it remains unclear whether there is still a place for using such a high-priced substance in the present cost-consciousness climate. Thus the Medical Council has presented some recommendations with regard to blood and plasma products including HA. There appear to be no indications for HA to correct hypovolemia either perioperatively or in the intensive care setting including children and patients undergoing cardiac or liver surgery. For maintaining colloid oncotic pressure (COP) cheaper modern synthetic colloids can be alternatively given and the value of HA for correcting hypoalbuminemia is also not clearly justified. Some small uncontrolled studies have shown that only patients with liver cirrhosis, spontaneous bacterial peritonitis and massive ascites drainage may profit from HA. Theoretical benefits such as oxygen radical scavenging or binding of toxic substances are no indications for using HA as beneficial clinical consequences have not yet been demonstrated. Experimental data from cell lines or animals must be viewed with skepticism because they do not mimic the clinical setting. According to the recommendations of the scientific advisory board of the Medical Council the use of HA should be considered very cautiously.
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Affiliation(s)
- J Boldt
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum der Stadt Ludwigshafen, Bremserstr. 79, 67063 Ludwigshafen, Deutschland.
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EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010; 53:397-417. [PMID: 20633946 DOI: 10.1016/j.jhep.2010.05.004] [Citation(s) in RCA: 1085] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 05/25/2010] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Patients with cirrhosis have total extracellular fluid overload but central effective circulating hypovolaemia. The resulting neurohumoral compensatory response favours the accumulation of fluids into the peritoneal cavity (ascites) and may hinder renal perfusion (hepatorenal syndrome). Their deranged systemic haemodynamics (hyperdynamic circulatory syndrome) is characterized by elevated cardiac output with decreased systemic vascular resistance and low blood pressure. RECENT FINDINGS Molecular and biological mechanisms determining cirrhosis-induced haemodynamic alterations are progressively being elucidated. The need for a goal-directed assessment of volume resuscitation (especially with volumetric techniques) in patients with cirrhosis is becoming more and more evident. The role of fluid expansion with albumin and the use of splanchnic vasopressors in a variety of cirrhosis-related conditions has recently been investigated. SUMMARY The response to fluid loading in patients with advanced cirrhosis is abnormal, primarily resulting in expansion of their noncentral blood volume compartment. Colloid solutions, in particular albumin, are best used in these patients. Albumin may be effective in preventing the haemodynamic derangements associated with large-volume paracentesis (paracentesis-induced circulatory dysfunction), in preventing renal failure during spontaneous bacterial peritonitis and, in association with splanchnic vasopressors, in caring for patients with the hepatorenal syndrome.
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Abstract
Ascites is a classic complication of advanced cirrhosis and it often marks the first sign of hepatic decompensation. Ascites occurs in more than 50% of patients with cirrhosis, worsens the course of the disease, and reduces survival substantially. Portal hypertension, splanchnic vasodilatation, liver insufficiency, and cardiovascular dysfunction are major pathophysiological hallmarks. Modern treatment of ascites is based on this recognition and includes modest salt restriction and stepwise diuretic therapy with spironolactone and loop-diuretics. Tense and refractory ascites should be treated with large volume paracentesis followed by plasma volume expansion or transjugular intrahepatic portosystemic shunt. Ascites complicated by spontaneous bacterial peritonitis requires adequate treatment with antibiotics. New potential treatment strategies include the use of vasopressin V(2)-receptor antagonists and vasoconstrictors. Since formation of ascites is associated with a poor prognosis, and treatment of fluid retention does not substantially improve survival, such patients should always be considered for liver transplantation.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology 239, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Hvidovre, Denmark.
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