Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial

Abstract

Introduction Circulatory dysfunction in cirrhotic patients may cause a specific kind of functional renal failure termed hepato-renal syndrome (HRS). It contributes to the high incidence of renal failure in cirrhotic intensive care unit (ICU) patients. Fluid therapy may aggravate renal failure by increasing ascites and intra-abdominal pressure (IAP). This study investigates the short-term effects of paracentesis on haemodynamics and kidney function in volume resuscitated patients with HRS. Methods Nineteen consecutive cirrhotic patients with HRS were studied. Circulatory parameters and renal function were analysed before and after plasma expansion and paracentesis. Haemodynamic monitoring was performed by transpulmonary thermodilution. Results After infusion of 200 ml of 20% human albumin solution, mean arterial pressure (MAP) and central venous pressure remained unchanged. Global end-diastolic volume index (GEDVI) increased from 791 ml m -2 (693 to 862) (median and 25th to 75th percentile) to 844 ml m -2 (751 to 933). Cardiac index (CI) increased from 4.1 l min -1 m -2 (3.6 to 5.0) to 4.7 l min -1 m -2 (4.0 to 5.8), whereas systemic vascular resistance index (SVRI) decreased from 1,422 dyn s cm -5 m -2 (1,081 to 1,772) to 1,171 dyn s cm -5 m -2 (893 to 1,705). Creatinine clearance (CC) and fractional excretion of sodium (FeNa) were not affected. During paracentesis, IAP decreased from 22 mmHg (18 to 24) to 9 mmHg (8 to 12). MAP decreased from 81 mmHg (74 to 100) to 80 mmHg (71 to 89), and CI increased from 4.1 l min -1 m -2 (3.2 to 4.3) to 4.2 l min -1 m -2 (3.6 to 4.7), whereas SVRI decreased from 1,639 dyn s cm -5 m -2 (1,168 to 2,037) to 1,301 dyn s cm -5 m -2 (1,124 to 1,751). CC during the 12-hour interval after paracentesis was significantly higher than during the 12 hours before (33 ml min -1 (16 to 50) compared with 23 ml min -1 (12 to 49)). CC remained elevated for the rest of the observation period. FeNa increased after paracentesis but returned to baseline levels after 24 hours. Conclusion Paracentesis with parameter-guided fluid substitution and maintenance of central blood volume may improve renal function and is safe in the treatment of ICU patients with hepato-renal failure.

The polycompartment syndrome: a concise state-of-the-art review

“…Increases in IAP may furthermore contribute to the progressive dilatation that precedes the rupture of the varices resulting in new oesophageal bleeding [135]. In patients with portal hypertension and tense ascites, paracentesis may improve variceal wall stress [136] and kidney function if euvolaemia is maintained [137]. Orthotopic liver transplantation is the best current treatment and leads to a gradual recovery of renal function in the vast majority of patients.…”

It is reasonable to treat patients with type 1 hepatorenal syndrome with midodrine and octreotide

“…The only statistically significant distinction between the two groups was the serum albumin value, which was actually higher in the control group. Given that other studies have suggested the benefits of albumin administration in HRS 5,6 , this difference could have been expected to improve outcomes in the control group. The article also does an excellent job of selecting clinically relevant outcomes.…”

“…3,4 Other prospective studies supporting solely albumin for plasma expansion were not chosen due to their small population size. 5,6 Another prospective study evaluating the efficacy of midodrine plus octreotide versus dopamine was discounted due to its results not having achieved significance. 7 Studies involving renal replacement therapy, TIPS procedure, and liver transplantation were also excluded because of their invasive nature.…”

Papel actual de la albúmina en cuidados críticos

“…La presencia de ascitis se relaciona directamente con la aparición de fallo renal; además, el 20% de los pacientes con ascitis a tensión desarrollan un síndrome hepatorrenal 34,35 . La presión intraabdominal disminuye la presión de perfusión renal y la filtración glomerular.…”