Automated low flow pump system for the treatment of refractory ascites: a single-center experience

Summary Background Few effective treatments are available for patients with cirrhosis and refractory ascites. New treatment modalities are needed for these patients. Aim To synthesise the available evidence on the efficacy and safety of automated low‐flow ascites pump therapy in patients with cirrhosis and refractory ascites. Methods Electronic databases were searched for trials evaluating automated low‐flow ascites pump therapy in patients with refractory ascites. Results Nine studies were included. Eight were case series, one was a randomised controlled trial. Pooled estimate rates were 0.62 (95% CI = 0.49‐0.74) for the absence of requirement of large volume paracentesis (LVP) after pump insertion, 0.30 (95% CI = 0.17‐0.47) for acute kidney injury, 0.27 (95% CI = 0.13‐0.49) for bacterial peritonitis and 0.20 (95% CI = 0.09‐0.37) for urinary tract infection. There was high heterogeneity between studies which was often reduced or eliminated in sensitivity analyses by excluding studies of patients with a mean or median model for end‐stage liver disease (MELD) score > 15. Results of sensitivity analyses were similar to those of overall analyses. Mean increase in serum creatinine level after pump insertion was 23 µmol/L (95% CI = 10‐35) with no heterogeneity between studies. The pooled estimate rate for pump‐related side effects was 0.77 (95% CI = 0.64‐0.87) with low heterogeneity between studies. Conclusion This meta‐analysis demonstrates that most patients treated with automated low‐flow ascites pump therapy do not require LVP after pump insertion. Acute kidney injury occurs in 30% of patients and creatinine levels increase by a mean of 23 µmol/L after pump insertion. Bacterial peritonitis and urinary tract infection occur in 27% and 20% of patients respectively.

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“…We screened 309 references; 40 were selected for full‐text retrieval. Of these, nine were included in the analysis …”

Section: Resultsmentioning

confidence: 99%

“…The methodological analysis of each study identified discrepancies in three studies in which median or mean MELD score was >15 (Table ). As MELD score might influence the rate of adverse events related to the procedure, sensitivity analyses excluding the Thomas, the Solbach and the Wong studies were performed.…”

Section: Resultsmentioning

confidence: 99%

Systematic review with meta‐analysis: automated low‐flow ascites pump therapy for refractory ascites

Lepida

Marot

Trépo

et al. 2019

Aliment Pharmacol Ther

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“…Our results are in keeping with those observed in this study, in which bacterial infections, hepatic encephalopathy, and AKI were also the most common cirrhosis‐related adverse events with 40, 17, and 13 episodes, respectively, in 40 patients. In a recent study that reports a single‐center experience with 10 patients who were treated with the alfa pump system, prerenal AKI was also reported as a common complication …”

Section: Discussionmentioning

confidence: 99%

Effects of alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites

et al. 2017

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The alfapump system has been proposed as a new treatment for the management of refractory ascites. The system removes ascites from the peritoneal cavity to urinary bladder, producing a continuous low-volume paracentesis. The aim of the study is to investigate the effects of treatment with the alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites. This was a prospective study including 10 patients with cirrhosis and refractory ascites. Primary outcomes were changes in glomerular filtration rate (GFR), as assessed by isotopic techniques, and changes in circulatory function assessed by arterial pressure, cardiac output, and activity of vasoconstrictor systems. Secondary outcomes were the need for large-volume paracentesis and adverse events. Follow-up was 1 year. GFR decreased significantly from 67 mL/minute/1.73 m (41-90 mL/minute/1.73 m ) at baseline to 45 mL/minute/1.73 m (36-74 mL/minute/1.73 m ) at month 6 (P = 0.04). Mean arterial pressure and cardiac output did not change significantly; however, there was a marked increase in plasma renin activity and norepinephrine concentration (median percent increase with respect to baseline +191% and 59%, respectively). There were 68 episodes of complications of cirrhosis in 8 patients during follow-up, the most frequent being acute kidney injury. In conclusion, treatment with alfapump™ system was associated with marked activation of endogenous vasoconstrictor systems and impairment of kidney function. The chronological relationship observed between kidney impairment and vasoconstrictor systems activation after device insertion suggests a cause-effect relationship, raising the possibility that treatment with alfapump impairs effective arterial blood volume mimicking a postparacentesis circulatory dysfunction syndrome. In this context, the potential role of albumin in counteracting these effects should be investigated in future studies. Liver Transplantation 23 583-593 2017 AASLD.

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“…Diuretics (e.g., furosemide and potassium-conserving diuretics) and a water-clearance mediator (e.g., tolvaptan) are available [71] . Hemodynamic disorders such as hepatic venous obstruction and portal thrombosis may develop if no response is observed after diuretic induction [72] . The most frequent cause of morbidity and mortality after LT is not immunological rejection but infectionrelated complications [73][74][75] .…”

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confidence: 99%

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

Hori

Ogura

Onishi

et al. 2016

WJH

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Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination Hori T et al . Peculiar hemodynamics in advanced cirrhosis constant (k ICG) in the well-preserved allograft. The k ICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.

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Automated low flow pump system for the treatment of refractory ascites: a single-center experience

Abstract: The Alfapump system is a useful system in the treatment of patients suffering from therapy refractory ascites. However, due to the high level of comorbidities, careful patient selection and postoperative monitoring are required.

Cited by 29 publications

References 26 publications

Systematic review with meta‐analysis: automated low‐flow ascites pump therapy for refractory ascites

Systematic review with meta‐analysis: automated low‐flow ascites pump therapy for refractory ascites

Effects of alfapump™ system on kidney and circulatory function in patients with cirrhosis and refractory ascites

Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation

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