Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites

Abstract

Paracentesis-induced circulatory dysfunction (PICD) is a recently described complication that can be prevented with the administration of plasma expanders. The aim of this study was to compare the efficacy of saline versus albumin in the prevention of PICD. Patients were randomized to receive albumin or saline after total paracentesis. Patients readmitted as a consequence of a second episode of tense ascites were treated with total paracentesis and the alternative plasma expander. After randomization, 35 patients received saline and 37 received albumin. Twenty-one patients were readmitted for tense ascites and treated with the alternative expander. Significant increases in plasma renin activity (PRA) were found 24 hours and 6 days after paracentesis when saline was used (baseline, 5.6 ؎ 5.7; 24 hours, 7.6 ؎ 6.9; 6 days, 8.5 ؎ 8.0 ng ⅐ mL ؊1 ⅐ hr ؊1 ; P < .05 and P < .01 vs. baseline, respectively), whereas no significant changes were observed with albumin. The incidence of PICD was significantly higher in the saline group versus the albumin group (33.3% vs. 11.4%, respectively; P ‫؍‬ .03). However, no significant differences were found when less than 6 L of ascitic fluid was evacuated (6.7% vs. 5.6% in the saline and albumin groups, respectively; P ‫؍‬ .9). Similar results were observed when analyzing patients who received 2 consecutive paracentesis (i.e., a significant increase in PRA after saline [P < .01] without significant variations after albumin). In conclusion, albumin is more effective than saline in the prevention of PICD. Saline is a valid alternative to albumin when less than 6 L of ascitic fluid is evacuated.

Evidence-based clinical practice guidelines for liver cirrhosis 2015

“…LVP is considered as the first-line therapy for tense ascites in the EASL guidelines [148] and AASLD guidelines [149]. Although plasma expanders and saline could replace albumin when less than 5 L of ascitic fluid is evacuated in Europe [158,159], we should be more cautious about LVP for small Asian patients to prevent a risky underfilling state which may lead to hepatic encephalopathy or renal failure. The prognosis of patients does not improve with the procedure [160].…”

AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis

“…Since the early 1990s, less costly alternatives, such as crystalloids and artificial colloid volume expanders, have been compared to HA 15,[20][21][22][23][24][25][26] . When more than 5 L of ascites are removed, HA (6-8 g/L of ascites removed) has been found to more effective at preventing PPCD than the other plasma expanders in several studies 15,20,25,26 , although other investigations -all including very low numbers of patients -did not confirm this positive result [21][22][23][24] . In contrast, when less than 5 L of ascites are removed, the incidence of PPCD is low and dextran-70 (8 g/L of ascites removed), polygeline (150 mL/L of ascites removed) or saline (150 mL/L of ascites removed) show an efficacy similar to that of HA 15,25 .…”

“…When more than 5 L of ascites are removed, HA (6-8 g/L of ascites removed) has been found to more effective at preventing PPCD than the other plasma expanders in several studies 15,20,25,26 , although other investigations -all including very low numbers of patients -did not confirm this positive result [21][22][23][24] . In contrast, when less than 5 L of ascites are removed, the incidence of PPCD is low and dextran-70 (8 g/L of ascites removed), polygeline (150 mL/L of ascites removed) or saline (150 mL/L of ascites removed) show an efficacy similar to that of HA 15,25 . However, polygeline is no longer used in many countries because of the potential risk of transmission of prions 1 , while there are concerns about the possibility that dextrans and starches may induce renal failure 27 and accumulate in the liver 28 .…”

“…Despite this greater efficacy in preventing PPCD, randomised trials have not shown differences in the survival of patients receiving HA compared with that of patients given alternative treatments 15,25,34 . However, a recent meta-analysis indicates that HA after largevolume paracentesis is significantly more effective than other treatments at reducing not only PPCD and hyponatraemia, but also mortality 35 .…”

Surgery in a Patient with Liver Disease

“…The incidence of PICD is reduced by pre-emptive administration of intravenous albumin at 6-8 g/L of ascites removed. 39 Large volume ascites will benefit from pre-operative paracentesis, diuretic therapy, and stringent limitation of sodium intake to 2 g/day to minimize reaccumulation of the ascitic fluid. In a patient with refractory ascites planned for surgery, TIPS may be used to control the ascites if the patient does not have any contraindication for TIPS and has a MELD score <18.…”