Cirrhotic Patients Refractory to Combination Diuretics

The massive ascites and edema of some cirrhotic patients cannot be reduced despite the above therapeutic interventions. In such patients large volume paracentesis (5-8 liters) can alleviate many of the symptoms associated with tense ascites. In the past, large volume paracentesis was discouraged for fear that it would produce severe intravascular volume depletion and cardiovascular collapse. However, recent studies show that large volume paracentesis can be safely carried out [11]. Indeed, several controlled studies suggest that the complication rate associated with this procedure is lower than that produced by aggressive diuretic therapy. Large volume paracentesis has become a relatively common outpatient procedure [8].

Intravenous expansion with albumin or nonprotein colloids is sometimes combined with paracentesis but the benefit of such adjunctive therapy generally remains unproven. If large volume paracentesis produces hemodynamic instability, or if more than 5 liters of ascitic fluid is to be removed, then postparacentesis azotemia and hyponatremia may be minimized by the administration of 40-60 g of albumin intravenously [9].

Ascites reinfusion simultaneously reduces the ascitic volume and expands the intravascular compartment. For selected patients, ascites reinfusion may correct the low EABV and reverse diuretic resistance. More recently, internal subcutaneous peritoneovenous shunts have been utilized for this purpose [ 14]. These internal shunts, inserted under local anesthesia, are associated with a relatively low incidence of infection, permit rapid ambulation and may contribute to earlier hospital discharge. However, peritoneovenous shunts are also associated with a number of complications including disseminated intravascular coagulation, variceal bleeding, and sepsis. Shunt failure due to canula occlusion also occurs commonly. When first introduced, these shunts were considered a major advance and were widely utilized. However, experience has tempered enthusiasm for this approach. Although peritoneovenous shunts reduce certain categories of morbidity, they simultaneously increase other forms of morbidity and have had little impact on overall mortality [27]. Peritoneovenous shunts are now considered a therapeutic option only when end-stage cirrhotic patients have become diuretic resistant.

The transjugular intrahepatic porta-systemic shunt is in an expandable metal mesh intravascular stent used to create a fistula between the hepatic venous and portal venous circulations. The device, inserted percutaneously, reduces portal pressures and was first deployed to treat variceal bleeding [3]. However, it was soon noted that coexistent ascites often improved or resolved after placement of such shunts. Apparently, the reduction in hepatic sinusoidal and splanchnic pressures together with increased cardiac return reduced the ascitic formation rate and increased renal salt excretion [34], This device has been most often used in patients with end-stage liver disease.

ACKNOWLEDGMENT

The authors acknowledge the secretarial support provided by Ann Drew in the preparation of the manuscript.

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SUGGESTED READING

35. Aiza, L, Perez, G. O., and Schiff, E. R. (1994). Management of ascites in patients with chronic liver disease. Am. J. Gastroenterol. 89, 1949-1956.

36. Ellison, D. H. (1994). Diuretic drugs and the treatment of edema: From clinic to bench and back again. Am. J. Kidney Dis. 23, 623-643.

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