Treatment of ascites with A single total paracentesis

Repeated large‐volume paracentesis (4–6 L/day) is an effective and safe therapy of ascites in patients with cirrhosis provided albumin is infused intravenously. To investigate whether ascites can be safely mobilized in only one paracentesis session (“total paracentesis”), 38 cirrhotic patients with tense ascites were treated with total paracentesis plus intravenous albumin (6–8 g/L ascites removed). Standard liver tests and renal function tests, glomerular filtration, free water clearance, plasma volume, plasma renin activity or plasma aldosterone and norepinephrine concentrations were measured before and after treatment. Total paracentesis was effective in mobilizing ascites in all but one patient and did not impair any of the parameters studied. The volume of ascitic fluid removed and the duration of the procedure was 10.7 + 0.5 L (mean + SEM) and 60 + 3 min, respectively. Five of the 38 patients (13%) developed complications during the first hospital stay (hepatic encephalopathy and gastrointestinal hemorrhage in 2 patients each and culture‐negative bacterial peritonitis in 1). No patient developed renal impairment. The complication rate, as well as the clinical course of the disease during follow‐up, estimated by the probability of readmission to hospital, causes of readmission and survival probability after treatment, was similar to that reported in patients treated with repeated large‐volume paracentesis. These results indicate that total paracentesis associated with intravenous albumin can be safely performed in cirrhotic patients with tense ascites and suggest that these patients could be treated in a single‐day hospitalization regime. To investigate whether albumin can be substituted by less expensive plasma expanders in cirrhotic patients with tense ascites treated with total paracentesis, 88 patients (16 with renal failure) submitted to this therapeutic procedure were randomly assigned to receive IV albumin (43 patients) or dextran‐70. Both substances were given at a dose of 8 g/L of ascitic fluid removed. Patients were discharged from the hospital with diuretics, and cases developing tense ascites during follow‐up were treated according to their initial schedule. Total paracentesis was effective in eliminating the ascites in all but two cases in each group. Neither paracentesis plus IV albumin infusion nor paracentesis plus IV dextran‐70 infusion was associated with significant changes in renal and hepatic function or serum electrolytes. The incidence of renal impairment (one case in each group), hyponatremia (three and four cases, respectively), and other complications (hepatic encephalopathy, gastrointestinal hemorrhage, bacterial infections) after paracentesis, and the clinical course of the disease, as estimated by the probability of readmission to hospital during follow‐up, causes of readmission, probability of survival, and causes of death were similar in the two groups of patients. The effect of paracentesis on effective intravascular volume was indirectly assessed by measuring plasma renin activity and aldosterone concentration before and 2 and 6 days after treatment, the patients being without diuretics. In patients treated with albumin, no significant changes in renin and aldosterone were observed during the entire period of observation. In contrast, both parameters increased significantly on the 6th day of treatment in patients receiving dextran‐70. A significant increase in plasma renin activity and aldosterone concentration (30% over baseline values) was observed in 51% of patients treated with dextran‐70 and in only 15% of patients treated with albumin (x 2 = 10.4; p = 0.0012). These results indicate that although dextran‐70 is less efficacious than albumin in protecting cirrhotic patients treated with total paracentesis from the decrease in effective intravascular volume, it appears to be capable of preventing the renal and electrolyte complications induced by this therapeutic procedure.