The Serum-Ascites Albumin Gradient Is Superior to the Exudate-Transudate Concept in the Differential Diagnosis of Ascites

Runyon, Bruce A.; Montano, Agnes A.; Akriviadis, Evangelos; Antillon, Mainor R.; Irving, Michelle; McHutchison, John G.

doi:10.7326/0003-4819-117-3-215

Cited by 559 publications

(449 citation statements)

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“…For patients with variceal hemorrhage, the decision to perform TIPS was determined by consensus between the referring hepatologist and the interventional radiologist on the basis of esophagogastroduodenoscopy findings, the patients' response to endoscopic management, and the perceived risk of future hemorrhage. For patients with ascites, the decision to proceed with TIPS was made on the basis of the criteria of Runyon et al for a serum-ascites albumin gradient Ͼ 1.1, 26 ascites consistent with a hepatogenic cause, and ascites refractory to medical therapy, as determined by our referring hepatologist. Two patients with ascites and colon carcinoma underwent TIPS to allow resection of their primary malignancy.…”

Section: Methodsmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Wallace

Madoff

Ahrar

et al. 2004

Cancer

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BACKGROUNDTransjugular intrahepatic portosystemic shunt (TIPS) placement has emerged as an effective and minimally invasive method of treating portal hypertension and its associated complications. To the authors' knowledge there is limited documentation of its use for percutaneous shunting in patients with hepatic and extrahepatic malignancies. The current study reports the authors' experience with TIPS in the oncology setting.METHODSThirty‐eight patients with cancer underwent TIPS procedures. Nineteen patients had a history of hepatic malignancy. All medical records and imaging studies were reviewed retrospectively. The indication for TIPS, the presence of malignancy, procedural details, complications, survival, and treatment success were assessed.RESULTSPrimary technical success was accomplished in 37 of 38 patients (97%) without technical procedure‐related complications. Hepatic encephalopathy occurred in 15 of 34 patients (44%), with 3 patients requiring shunt reduction. Premature shunt occlusion (< 30 days) occurred in 3 patients (8%). Recurrent hemorrhage occurred in 1 of 19 patients (5%), and ascites and hepatic hydrothorax resolved or improved subjectively in 9 of 12 patients (75%). Shunts traversed malignancy in 9 patients, and varying degrees of portal compromise were encountered in 12 patients (32%). The overall 30‐day and 90‐day survival rates were 84% and 60%, respectively. There was a statistically significant difference in 90‐day survival rates for patients who had ascites and hepatic hydrothorax indications (27%) compared with patients who had variceal and portal gastropathy indications (84%; P = 0.0075). In addition, the 90‐day survival rate was significantly lower in patients who had primary hepatic malignancies (36%) compared with the remainder of the study population (74%; P = 0.0077), and it was significantly lower in patients who had model for end‐stage liver disease (MELD) scores ≥ 12 (P = 0.0020).CONCLUSIONSTIPS was performed safely for patients with cancer without increasing rates of procedure‐related complications. However, some patients subgroups, such at those with malignancy and ascites, primary hepatic malignancy, or MELD scores ≥ 12, had the lowest 90‐day survival rates. Cancer 2004. © 2004 American Cancer Society.

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Section: Methodsmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Wallace

Madoff

Ahrar

et al. 2004

Cancer

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Section: Discussionmentioning

confidence: 99%

“…12 The serum-ascites albumin gradient has been proved in prospective studies to categorize ascites better than the total-protein based exudate/transudate concept and than the modified pleural fluid exudate/trandudate criteria. [15][16][17] Calculating the serum-ascites albumin gradient involves measuring the albumin concentration of serum and ascitic fluid specimens and subtracting the ascitic fluid value from the serum value. With approximately 97% accuracy, a serum-ascites albumin gradient of H1.1 g/dL (11 g/L) indicates that the patient has portal hypertension.…”

Section: Discussionmentioning

confidence: 99%

“…Approximately 5% of patients with ascites have two or more causes of ascites formation, i.e., ''mixed'' ascites. 15,25 Usually these patients have cirrhosis plus one other cause, e.g., peritoneal carcinomatosis or peritoneal tuberculosis. Many patients with enigmatic ascites are eventually reported to have 2 or even 3 causes for ascites formation, such as heart failure and diabetic nephropathy.…”

Section: Differential Diagnosismentioning

confidence: 99%

“…With approximately 97% accuracy, a serum-ascites albumin gradient of H1.1 g/dL (11 g/L) indicates that the patient has portal hypertension. 15 Conversely, a serum-ascites albumin gradient of Ͻ1.1 g/dL (11 g/L) with Ϸ97% accuracy that the patient does not have portal hypertension.Patients undergoing serial outpatient therapeutic paracenteses probably should be tested only for cell count and differential; bacterial culture is not necessary in asymptomatic patients. 18 The most expensive tests are the cytology and smear and culture for mycobacteria; these tests should probably be ordered only when there is a high pretest probability of occurrence of the disease under consideration.…”

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Management of adult patients with ascites caused by cirrhosis

Runyon¹

1998

Hepatology

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302

131

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Ascites is the most common of the major complications of cirrhosis. The development of ascites is an important landmark in the natural history of cirrhosis and has been proposed as an indication for liver transplantation. The initial evaluation of a patient with ascites should include a history, physical evaluation, and abdominal paracentesis with ascitic fluid analysis. Treatment should consist of abstinence from alcohol, sodium restricted diet, and diuretics. This regimen is effective in Ϸ90% of patients. The treatment options for the diuretic-resistant patients include serial therapeutic paracenteses, liver transplantation, and peritoneovenous shunting. (HEPATOLOGY 1998;27;264-272.) PREAMBLE These guidelines provide a data-supported approach to the care of patients with ascites. They are based on the following: 1) a formal review and analysis of the published world literature (1,045 papers) on ascites (Medline Search from 1966-1996, search terms included ascites, diet therapy, drug therapy, radiotherapy, surgery, and therapy); 2) the American College of Physician' s Manual for Assessing Health Practices and Designing Practice Guidelines 1 ; and 3) several published and draft guidelines, including the American Association for the Study of Liver Diseases' Policy Statement on Development and Use of Practice Guidelines and American Gastroenterological Association' s Policy Statement on Guidelines 2 ; and 4) 15 years of experience on the part of the author in the clinical and laboratory investigations of and care for patients with this problem.These guidelines, intended for use by physicians, suggest preferable approaches to the diagnostic, therapeutic, and preventative aspects of care. These guidelines are intended to be flexible, in contrast with ''standards of care,'' which are inflexible policies to be followed in almost every case. 1 Furthermore, these guidelines were developed for the care of adult patients with clinically detectable ascites. Although the general approach may be applicable to children, the pediatric data base is much smaller and there may be unanticipated differences between adults and children. Patients with ascites that is detected by imaging modalities alone, but not yet clinically evident, are not included because of the lack of published information regarding the natural history of this entity.Specific recommendations are based on relevant published information. In an attempt to standardize recommendations, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases modified the categories of the Infectious Diseases Society of America' s Quality Standards. 3 These categories are reported with each recommendation, using the letters A through E to determine the strength of recommendation and roman numerals I through III to determine quality of evidence upon which recommendations are based, as follows: A, survival benefit; B, improved diagnosis; C, improvement in quality of life; D, relevant pathophysiologic parameters improved; E, impacts cost of heal...

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Evaluation of New-Onset Ascites

Patel

Muir

2016

JAMA

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The Serum-Ascites Albumin Gradient Is Superior to the Exudate-Transudate Concept in the Differential Diagnosis of Ascites

Abstract: The exudate-transudate concept should be discarded in the classification of ascites. The serum-ascites albumin gradient is far more useful than the AFTP as a marker for portal hypertension, but the latter remains a useful adjunct in the differential diagnosis of ascites.

Cited by 559 publications

References 32 publications

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Management of adult patients with ascites caused by cirrhosis

Evaluation of New-Onset Ascites

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