Immune-Inflammatory and Metabolic Effects of High Dose Furosemide plus Hypertonic Saline Solution (HSS) Treatment in Cirrhotic Subjects with Refractory Ascites

Tuttolomondo, Antonino; Raimondo, Domenico Di; Bellia, Chiara; Clemente, Giuseppe; Pecoraro, Rosaria; Maida, Carlo; Simonetta, Irene; Vassallo, Valerio; Bona, Danilo Di; Gulotta, Eliana; Ciaccio, Marcello; Pinto, Antonio

doi:10.1371/journal.pone.0165443

Cited by 11 publications

(9 citation statements)

References 33 publications

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“…The inflammatory and metabolic effect of saline overload correction in treatment of cirrhosis complications suggested a possible role of inflammatory and metabolic-nutritional variables as severity markers in these patients [ 22 ]. Moreover, several investigations have characterized HS in terms of its specific immune-modulatory qualities, such as monocyte subset redistribution and cytokines production [ 20 , 23 ].…”

Section: Discussionmentioning

confidence: 99%

Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery

Xin

Chen

et al. 2017

J Neuroinflammation

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BackgroundPostoperative delirium (POD) is a common disorder in the elderly patients, and neuroinflammation is the possible underlying mechanism. This study is designed to determine whether or not hypertonic saline (HS) pre-injection can alleviate POD in aged patients.MethodsThis prospective study recruited 120 geriatric patients who underwent hip surgery. The patients were randomly divided into two groups: control group (NS group) and HS group. Patients in the NS group were pre-injected with 4 mL/kg isotonic saline, and those in the HS group were pre-injected with 4 mL/kg 7.5% HS. All 120 patients were then subjected to general anesthesia. Blood samples were extracted to detect the concentration of inflammatory factors, namely, IL-1β, IL-6, IL-10, and TNF-α, and the nerve injury factor S100β. Flow cytometry was used to detect the number of monocytes in peripheral venous blood and evaluate the relationship of inflammation to delirium. The nursing delirium screening scale (Nu-DESC) was used to determine cognitive function 1 to 3 days postoperatively.ResultsAnalysis using random-effect multivariable logistic regression indicated that HS administration before anesthesia was associated with a low risk of POD (odds ratio [OR], 0.13; 95% CI, 0.04 to 0.41; P = 0.001) and few CD14 + CD16+ monocytes (β = − 0.61; 95% CI, − 0.74 to − 0.48; P = 0.000) the following day. When the association between HS and delirium was controlled for CD14 + CD16+ monocytes, the effect size became nonsignificant (odds ratio [OR], 0.86; 95% CI, 0.14 to 5.33; P = 0.874). TNF-α was significantly associated with POD (odds ratio [OR], 1.10; 95% CI, 1.05 to 1.16; P = 0.000). However, IL-1β, IL-6, IL-10, and S100β were not significantly related to POD.ConclusionHS can alleviate POD in geriatric patients and may inhibit the secretion of inflammatory factors by monocytes.

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Section: Discussionmentioning

confidence: 99%

Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery

Xin

Chen

et al. 2017

J Neuroinflammation

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“…Furosemide before the hospice admission usually administered orally failed to adequately control salt and water retention despite dose escalation [21]. One of the strategies for overcoming this resistance is adding hypertonic saline solution [22] that probably restore the effective arterial volume and improve neurohormonal inhibition and renal hemodynamics [23]. However, possible short term risk factors of diuretics (e.g.…”

Section: Discussionmentioning

confidence: 99%

“…In the hospice setting simple physical examination monitoring of the neck veins and blood pressure are valuable [21]. In addition, the serial measures of hematocrit levels, indicating for the adequacy of fluid refilling rate from the extravascular to the vascular compartment could be helpful [22]. Compression limb bandaging, in turn, added to diuretics may promote the compensation of an excessively fast vessel fluid withdrawal.…”

Section: Discussionmentioning

confidence: 99%

Limb edema in patients with advanced disease — a pilot study of compression therapy combined with diuretics

Grądalski¹

2019

Palliat Med Pract

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Introduction. Management of edema due to advanced disease is seldom recognized in palliative care. The purpose of this pilot study was to assess the effectiveness and tolerance of conservative edema therapy. Material and methods. Prospective analysis of limb volumes, edema symptom burden and quality of life (QoL) in 119 patients diagnosed with edema was performed. Eighteen patients in their last days of life complaining of edema were treated by limb elevation, supportive (palliative) bandaging, manual lymphatic drainage, Kinesio Taping and/or controlled subcutaneous needle drainage. Forty-six with longer prognosis were treated by one-week multilayer short-stretch limb bandaging and then re-evaluated. Twenty-eight of them with venous congestion resistant to previously given diuretics received additionally furosemide infusion in hypertonic saline. Subgroups analysis of the patients with diuretic therapy and primary lymphatic congestion was performed. Results. Within 46 patients re-evaluated the reduction of limb volume was accompanied by a decrease of edema symptom intensity and an improvement of QoL. Subgroup analysis revealed both volume and symptomatic improvement, equally effective in cases with suspected lymphatic congestion or when diuretics were added. Conclusion. Edema of advanced disease irrespective of the lymphatic component can be effectively managed conservatively with short-stretch limb bandaging. In cases resistant to oral diuretic fluid overload, parenteral hypersaline furosemide addition to the compression may be the safe therapeutic option enhancing treatment tolerance.

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“…They later found significant reductions of serum levels of natriuretic peptides (ANP and brain natriuretic peptide [BNP]) and inflammatory cytokines (TNF-α, interleukin [IL] 1β, and IL-6) in patients with refractory ascites treated with the high-dose furosemide+HSS injection compared with those treated with serial paracentesis. 99 Salt ingestion therapy is quite the opposite of the traditional principles of ascites management indicating salt restriction. This treatment has never been discussed in the major clinical guidelines, although HSS is indicated in symptomatic patients with profound hyponatremia who are intolerant or unresponsive to free water restriction.…”

Section: Experimental Treatmentsmentioning

confidence: 99%

“…While elevated serum BNP level is considered to reflect left ventricular myocardial dysfunction (impaired systolic function and/or diastolic relaxation), 101 – 103 an elevated serum ANP level is attributable to increased atrial volume or pressure. 101 , 103 , 104 The latter may reflect increased blood volume in liver cirrhosis (overflow state), 104 although a study by Tuttolomondo et al 99 did not concomitantly evaluate RAAS or SNS. It is presumed that high-dose furosemide+HSS may be effective for refractory ascites associated with cirrhotic cardiomyopathy and hypervolemia.…”

Section: Experimental Treatmentsmentioning

confidence: 99%

Management of refractory cirrhotic ascites: challenges and solutions

Fukui¹,

Kawaratani²,

Kaji³

et al. 2018

HMER

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Among the various risky complications of liver cirrhosis, refractory ascites is associated with poor survival of cirrhotics and persistently worsens their quality of life (QOL). Major clinical guidelines worldwide define refractory ascites as ascites that cannot be managed by medical therapy either because of a lack of response to maximum doses of diuretics or because patients develop complications related to diuretic therapy that preclude the use of an effective dose of diuretics. Due to the difficulty in receiving a liver transplantation (LT), the ultimate solution for refractory ascites, most cirrhotic patients have selected the palliative therapy such as repeated serial paracentesis, transjugular intrahepatic portosystemic shunt, or peritoneovenous shunt to improve their QOL. During the past several decades, new interventions and methodologies, such as indwelling peritoneal catheter, peritoneal-urinary drainage, and cell-free and concentrated ascites reinfusion therapy, have been introduced. In addition, new medical treatments with vasoconstrictors or vasopressin V2 receptor antagonists have been proposed. Both the benefits and risks of these old and new modalities have been extensively studied in relation to the pathophysiological changes in ascites formation. Although the best solution for refractory ascites is to eliminate hepatic failure either by LT or by causal treatment, the selection of the best palliative therapy for individual patients is of utmost importance, aiming at achieving the longest possible, comfortable life. This review briefly summarizes the changing landscape of variable treatment modalities for cirrhotic patients with refractory ascites, aiming at clarifying their possibilities and limitations. Evolving issues with regard to the impact of gut-derived systemic and local infection on the clinical course of cirrhotic patients have paved the way for the development of a new gut microbiome-based therapeutics. Thus, it should be further investigated whether the early therapeutic approach to gut dysbiosis provides a better solution for the management of cirrhotic ascites.

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Immune-Inflammatory and Metabolic Effects of High Dose Furosemide plus Hypertonic Saline Solution (HSS) Treatment in Cirrhotic Subjects with Refractory Ascites

Cited by 11 publications

References 33 publications

Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery

Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery

Limb edema in patients with advanced disease — a pilot study of compression therapy combined with diuretics

Management of refractory cirrhotic ascites: challenges and solutions

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