Ascites in patients treated with maintenance hemodialysis

Ascites development is associated with worse outcome in patients after kidney transplantation

BACKGROUND

We provide detailed analysis and outcomes in patients post-kidney transplant (KT) developing ascites, which has never been categorically reported.

METHODS

Ascites was identified by ICD9/10 codes and detailed chart review in patients post-KT from 01/2004-06/2019. The incidence of patient death and graft loss were determined per 100-person-years, and the incidence rate ratio was obtained.

RESULTS

Of 3329 patients receiving KT, 83 (2.5%) patients had new-onset ascites, of whom 58% were male, 21% blacks, and 29% whites. Seventy-five percentage were on hemodialysis. Patients were maintained primarily on tacrolimus and mycophenolate for immunosuppression. Only 14% of patients with ascites had the appropriate diagnostic workup. There was a trend toward an increased mortality in patients with ascites (incidence rate ratio, IRR [95% CI]: 1.8 [0.92, 3.19], p = .06), and a significantly higher incidence of graft loss (IRR: 5.62 [3.97, 7.76], p < .001), compared with non-ascites patients. When classified by ascites severity, determined by imaging, moderate/severe ascites patients had the worst clinical outcomes, with a mortality of 32% and graft failure in 57%, compared with 9% and 10%, respectively, in those without ascites.

CONCLUSION

In this large cohort employing stepwise analysis of ascites post-KT, worse outcomes were noted, dictating the need for optimized management to improve clinical outcomes.

Peritoneal Dialysis in the Comprehensive Management of End-Stage Renal Disease Patients with Liver Cirrhosis and Ascites: Practical Aspects and Review of the Literature

The treatment of cirrhotic patients with ascites and end-stage renal disease is complex, due mainly to decreased effective arterial volume and hemodynamic instability. Peritoneal dialysis as a continuous therapy represents an alternative to hemodialysis-related intolerance. We report on our experience and that of others with cirrhotic patients with ascites treated by peritoneal dialysis. Hemodynamic tolerance was excellent in all patients and solute and water peritoneal transport increased to above the normal range in almost all cases. Morbidity and mortality were related principally to liver disease and other comorbidities. Peritoneal protein losses, initially high, decreased over time, maintaining serum albumin within the low normal range. The incidence of peritonitis was similar or slightly higher than usual in these patients, with peculiar etiology. The experiences with peritoneal dialysis suggest consideration of this treatment as the first choice for cirrhotic patients with ascites and that need to start dialysis.

Complication of diagnostic pleural aspiration: is it of value in hemodialysis patients?

Pleural effusions are common in hemodialysis patients and are associated with significant morbidity. Diagnostic pleural aspiration and subsequent biochemical analysis can be used to differentiate exudates and transudates. In particular, Light's criteria have been validated in the general population although their efficacy in hemodialysis patients is unclear. Furthermore, aspiration is not without risk; we report the case of a life-threatening thoracic bleed as a complication of diagnostic thoracocentesis in a hemodialysis patient, in whom a transudative effusion was misclassified according to Light's criteria. Retrospective examination of a further 22 aspirations in hemodialysis patients suggests that biochemical analysis of pleural fluid in this group is of limited value. Careful clinical and radiological assessment may be of greater value in determining individuals who may benefit from formal drainage, rather than diagnostic aspiration with its attendant risks.

Ascites and kidney transplantation: case report and critical appraisal of the literature

Ascites is an ominous finding after kidney transplantation. It occurs either as a result of technical complication of the transplant procedure or from medical reasons that include portal hypertension, graft rejection and other causes (1, 2). Here in are described a case of ascites that occurred after successful kidney transplantation. Kidney re-transplantation alone or combined heart and kidney transplantation were possible options for him. Finally, a review of published cases of ascites that occurred after kidney transplantation and treatment of putative nephrogenic ascites (NA) is presented.

Outcome of renal transplantation in children with pericardiopleural effusion

INTRODUCTION

Children with end-stage renal disease may present with pericardiopleural effusion secondary to volume overload and overhydration. The present study was designed to investigate the efficacy and safety of renal transplantation in these pediatric patients.

METHODS

From 1981 to 2001, six of 20 patients (30%) under 18 years old who received renal transplants showed pericardiopleural effusion after serial pretransplant imaging studies. These patients also displayed associated diseases, such as congestive heart failure (n = 3), ascites (n = 2), and splenomegaly (n = 2). The recipients included five boys and one girl of mean age of 12.7 years (range, 8 to 17 years), all of whom had undergone hemodialysis before transplantation. The waiting time for grafts ranged from 1.3 to 6 years (mean = 2.6 years). Episodes of acute pulmonary edema had been observed in three patients pretransplant.

RESULTS

One recipient died with a functioning graft due to heart failure with acute pulmonary edema at 4 months after transplantation. Acute rejection episodes were observed in three, and chronic rejection in two children. The median follow-up was 11 years (range = 6 to 16 years) in the other five recipients, all of whom presently survive with functioning grafts. The posttransplant mean serum creatinine levels at 1 year, 3 years, and 5 years were 1.54 +/- 0.44, 1.74 +/- 0.56, and 1.92 +/- 0.56 mg/dL, respectively.

CONCLUSION

Renal transplantation in children displaying pericardiopleural effusion was associated with a high success rate. However, these patients must be followed closely with regular cardiopulmonary evaluation since their condition may deteriorate.

Nephrogenic ascites. Analysis of 16 cases and review of the literature

Nephrogenic ascites is an entity that manifests as refractory ascites in patients with end-stage renal disease, where portal hypertensive, infectious, and malignant processes have been excluded. Most of these patients are undergoing hemodialysis. Hypoalbuminemia may predispose these uremic patients to ascites formation. The characteristics of the ascitic fluid suggest that the pathogenesis of the ascites is an alteration in peritoneal membrane permeability or impaired resorption due to peritoneal lymphatic channel obstruction. The ascitic fluid has a high protein content, low serum-ascites albumin gradient (SAAG), and low leukocyte count. Daily hemodialysis should be the initial therapy and is successful in one-third to three-fourths of patients within 3 weeks. Continuous ambulatory peritoneal dialysis or insertion of a peritoneovenous shunt are alternative treatments. Other therapies include instillation of intraperitoneal corticosteroids and binephrectomy, which have less predictable outcomes. Renal transplantation is the definitive treatment for nephrogenic ascites. Control of ascites reverses the progressive cachexia associated with uncontrolled disease, resulting in improved quality of life and survival approaching that of end-stage renal disease patients without ascites.

Hemodynamic effects of peritoneovenous shunts in hemodialysis patients with ascites

Ascites in hemodialysis patients has been reported in association with systemic diseases, such as cirrhosis or congestive heart failure, and as an idiopathic form. Regardless of the etiology, these patients often are refractory to treatment with intradialytic ultrafiltration because of recurrent hypotensive episodes. In this report we describe the hemodynamic effects of peritoneovenous shunts (PVSs) in three hemodialysis patients with ascites refractory to conventional treatment. One patient had idiopathic ascites and the other two had associated liver disease. Patients were monitored for lowest blood pressure, number of intradialytic hypotensive episodes, number of grams of albumin infused to treat hypotensive episodes, interdialytic weight gain, and hemodynamic stability (defined as the difference between the predialysis mean arterial pressure and the lowest intradialytic mean arterial pressure). In all three patients the hemodynamic parameters stabilized after PVS placement despite equal or greater ultrafiltration during dialysis (due to a significant increase in the lowest measured intradialytic blood pressure). The total number of hypotensive episodes decreased from 219 prior to PVS placement to zero after shunt placement. The need for albumin infusion during hemodialysis (for blood pressure support) decreased (significantly in two patients), as did the volume of ascites in all three patients. One patient required PVS replacement secondary to infection, which was the only complication. We believe that refractory ascites in end-stage renal disease patients can be successfully treated by placement of a PVS, which often results in relief of the ascites and significant improvement in intradialytic hemodynamic stability.

Idiopathic dialysis ascites in the nineties: resolution after renal transplantation

The incidence of idiopathic dialysis ascites seems to have decreased since the introduction of more effective techniques for control of fluid overload and uremia in chronic hemodialysis patients. Most of the patients reported so far had some predisposing factor, such as malnutrition or sustained fluid overload. We report a case of idiopathic dialysis ascites in a young well-nourished woman with an excellent control of fluid overload and in whom biocompatible dialyzer membranes and volumetric controlled ultrafiltration had been used since her onset of chronic dialysis. Extensive studies excluded the existence of an underlying cause for ascites. Ascitic fluid had the characteristics of an exudate, and a peritoneal biopsy specimen showed chronic nonspecific inflammatory changes. Massive ascites persisted for 6 months, requiring repeated paracentesis, until the performance of a successful renal transplantation. Coinciding with the recovery of renal function, a dramatic disappearance of ascites was observed.

Ascites associated with end-stage renal disease

Patient characteristics, clinical outcomes, and proposed pathophysiologic mechanisms are reviewed in 138 patients reported in the literature to have had ascites associated with end-stage renal disease. Contributing mechanisms may include fluid overload, peritoneal membrane changes (not necessarily related to peritoneal dialysis), hypoproteinemia, and lymphatic drainage disturbances. In 15% of cases, extensive evaluations may reveal an underlying disease. The most effective therapy may be kidney transplantation.

Peritoneo-venous shunting in patients with cirrhotic ascites and end-stage renal failure

End-stage renal failure supervened in two cirrhotic patients with ascites, necessitating maintenance hemodialysis therapy. One patient had a functioning LeVeen peritoneo-jugular shunt (Becton-Dickinson, Rutherford, NJ) in place at the time that hemodialysis was initiated. In the other patient, a LeVeen shunt was inserted 8 months after beginning hemodialysis, after extracorporeal ultrafiltration had failed to resolve his ascites. Both patients achieved control of their ascites and enjoyed relatively long survival. Our results suggest that, in patients with cirrhotic ascites who develop end-stage renal failure, successful long-term management can be obtained using a combination of peritoneo-venous shunting and maintenance hemodialysis.

Isolated ultrafiltration in the treatment of dialysis ascites

Three patients with dialysis ascites improved markedly after treatment with isolated ultrafiltrations. This simple, noninvasive technique should be applied first to patients with dialysis ascites before resorting to more drastic therapeutic measures.

Intraperitoneal infusion of a nonabsorbable steroid in hemodialysis-associated ascites

Ascites occurring in long-term hemodialysis patients continues to be a difficult management problem. Several modalities have been employed with varying success. Because of the similarities between uremic pericardial effusion and hemodialysis-associated ascites, infusion of the nonabsorbable steroid, triamcinolone hexacetonide, was attempted in five patients with the latter ailment which had become intractable. None of the patients responded and in two there were adverse effects. We conclude that for the management of this variety of ascites, intraperitoneal administration of a nonabsorbable steroid is ineffective and may be accompanied by undesirable reactions.

Ascites following renal transplantation

Idiopathic ascites has been described in patients on maintenance peritoneal dialysis and hemodialysis. The mechanism responsible for ascites formation in these patients is unknown, and therapy has been generaly unsuccessful. However, renal transplantation has been associated with resolution of this form of ascites. We describe a patient who was free of ascites during maintenance dialysis, in whom ascites developed following renal transplantation associated with transient impairment of renal function. No specific cause of the ascites was found. Resolution of ascited occurred as renal function improved. This experience extends the spectrum of idiopathic ascites in uremic patients to the transplant recipient.

Ascites in patients undergoing maintenance hemodialysis. Report of six cases and physiopathologic approach

Six patients with chronic uremia in whom ascites developed during maintenance hemodialysis are described. Their clinical and biochemical findings are reviewed and compared with data of 10 hemodialyzed patients without ascites. Liver cirrhosis was the origin of ascites in only one case. Hypoalbuminemia, liver cirrhosis, congestive heart failure, peritonitis, peritoneal tuberculosis and carcinomatosis were uniformly absent in the other patients. Long-term and marked overhydration seems to be at the origin of ascites. Lack of peripheral edema, probably due to ascites compartmentalization, was a constant finding in every noncirrhotic patient with ascites. When long-term overhydration was stopped after successful kidney transplantation or by means of diminished water and salt ingestion, reversal of the syndrome was attained. Nevertheless, ascites because of liver cirrhosis was not influenced by means of kidney transplantation. In three patients with ascites who did not receive a transplant, a significant reduction in water and salt ingestion was reached after intensive psychotherapy which led to reversal of the ascitic syndrome. In one anephric patient ascites did not develop despite water overloading. Survival has not been influenced by the formation of ascites. Further research is needed to determine the mechanism of sodium transfer across the peritoneal membrane. Influence of humoral factors can be considered, if an active transport mechanism could be demonstrated.

The use of an indwelling peritoneal catheter in the treatment of chronic renal failure

Thirty-seven patients with end-stage renal failure were treated by dialysis by the peritoneal route, with a Tenckoff catheter. The basic regime was 30 2-litre exchanges twice a week. Two patients died while receiving peritoneal therapy, and 7 patients were transferred to haemodialysis because of catheter failure. Four patients received transplants directly from peritoneal dialysis, 22 were transferred electively to haemodialysis, and 2 are still being treated by peritoneal dialysis. Fourteen (1-2%) of the 1,161 dialyses were complicated by peritoneal infection. This was controlled in 13 instances by the addition of gentamicin to the dialysate, but removal of the catheter was required in one case. The mean duration of peritoneal dialysis was 14-4 weeks; 4 patients underwent this type of therapy for 78, 63, 41 and 40 weeks respectively.

The clinical spectrum of ascites associated with maintenance dialysis

Among 197 patients being treated with maintenance dialysis, six were found to have ascites. Unlike previous reported series, the cause of ascites and the clinical course were variable. Two patients responded to definitive therapy directed against the specific cause. No consistent association was found with the etiology of renal disease or therapy of uremia including the duration of hemodialysis or prior peritoneal dialysis. Nonspecific therapy attempting to alleviate ascites was unsatisfactory. Severe hypertension was not characteristic and bilateral nephrectomy did not influence the course. An extensive diagnostic evaluation is recommended along with skepticism before declaring that idiopathic, refractory ascites exists signaling progressive deterioration.