Long-term clinical outcome of large volume paracentesis with intravenous albumin in patients with spontaneous bacterial peritonitis: a randomized prospective study

Management of Ascites: AJR Expert Panel Narrative Review

Ascites can develop in the setting of a variety of pathologies. The approach to treatment depends on accurate determination of the underlying cause, for which fluid analysis plays a central role. In particular, the serum-ascites-albumin gradient serves as a primary diagnostic test for differentiating among causes, with certain additional fluid tests performed based on clinical suspicion. Treatment options range from nonspecific fluid removal, including large-volume paracentesis and tunneled peritoneal catheters, to targeted therapies (e.g., diuretics, transjugular intrahepatic portosystemic shunt, and lymphangiography). Societal guidelines exist for the approach to cirrhotic ascites, but the management of other less common causes remains less well defined. The goal of this AJR Expert Panel Narrative Review is to provide guidance for the diagnosis and management of ascites, based on available evidence and the authors' clinical experience.

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU.

DESIGN

The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development.

INTERVENTIONS

In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements.

MEASUREMENTS AND MAIN RESULTS

We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence.

CONCLUSIONS

Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.

[Ascites]

Ascites is the most common cause of decompensation in cirrhosis, and 5% to 10% of patients with compensated cirrhosis develop ascites each year. The main factor of ascites formation is renal sodium retention due to activation of the renin-angiotensin-aldosterone system and sympathetic nervous system by the reduced effective volume secondary to splanchnic arterial vasodilation. Diagnostic paracentesis is indicated in all patients with a new onset of grade 2 or 3 ascites and in those admitted to hospital for any complication of cirrhosis. A serum-ascites albumin gradient of ≥1.1 g/dL indicates portal hypertension with an accuracy of approximately 97%. Sodium restriction, diuretics, and large volume paracentesis are the mainstay of treatment in grade 1 to 3 ascites. The refractoriness of ascites is associated with a poor prognosis with a median survival of approximately six months. Repeated large volume paracentesis plus albumin is the first line treatment, and liver transplantation is recommended in patients with refractory ascites. A careful selection of patients is also important to obtain the beneficial effects of transjugular intrahepatic portosystemic shunts in refractory ascites. This review details the recent diagnosis and treatment of cirrhotic ascites.

Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications

Since the introduction of human serum albumin as a plasma expander in the 1940s, considerable research has allowed a better understanding of its biochemical properties and potential clinical benefits. Albumin has a complex structure, which is responsible for a variety of biological functions. In disease, the albumin molecule is susceptible to modifications that may alter its biological activity. During the last decades, different methods to measure albumin function have been developed. Recent studies have shown that not only albumin concentration but also albumin function is reduced in liver failure. This observation led to the concept of effective albumin concentration, which represents the fact that plasma albumin concentration does not reflect its function. Indeed, in liver disease albumin function is several times less than its concentration. In patients with cirrhosis, albumin infusion reduces mortality in patients with spontaneous bacterial peritonitis and improves outcome following large volume paracentesis. In combination with vasoconstrictors, albumin is useful in the management of patients with hepatorenal syndrome. Its role is being investigated in a large number of indications, which rely on its volume and nonvolume expansion functions such as stroke, severe sepsis, Alzheimer's disease, malaria, burns, and ovarian hyperstimulation syndrome. This review explores the above concepts, reviews the available evidence for the use of albumin in liver diseases, defines therapeutic limitations, and explores the challenges that should be addressed in future research.

Evaluation of different therapeutic approaches for spontaneous bacterial peritonitis

BACKGROUND AND STUDY AIMS

Spontaneous bacterial peritonitis (SBP) is a significant cause of mortality in cirrhosis. Reducing toxic burden of infected ascitic fluid through paracentesis needs further studies as adjunctive therapy of SBP. We aimed to evaluate different therapies for SBP.

PATIENTS AND METHODS

Thirty-six cirrhotic ascitic patients with SBP were examined and classified according to treatment modality (5-7 days) into: Group A received cefotaxime, group B received cefotaxime and albumin 1.5 g/kg body weight within 6h of SBP being diagnosed and 1g/kg body weight on day 3, group C received cefotaxime and paracentesis with volume dependent albumin infusion. Control group of 12 cirrhotic ascitic patients free from SBP were included. Routine laboratory tests, ascitic fluid analysis for leucocytes and culture were done, inflammatory mediators such as nitric oxide and tumour necrosis factor alpha were measured in serum and ascitic fluid. Duplex-Doppler assessment of portal flow volume and renal resistive index, Echocardiography to measure end diastolic and end systolic volumes, stroke volume and cardiac output were done. Tests were carried out before and after therapy.

RESULTS

Treatment response was assessed by, cardiac haemodynamics, portal and renal flow and NO and TNF. All studied parameters; laboratory, cardiac, Doppler exhibited a significant improvement in group B in contrast to the other groups as demonstrated by post therapy reduction of (blood and ascitic fluid WBCs & PNLS, serum and ascitic NO & TNF and renal resistive index), elevation of (serum albumin and portal flow volume) and improvement of cardiac haemodynamic.

CONCLUSION

Treatment of spontaneous bacterial peritonitis by cefotaxime and body weight based albumin infusion gave most favourable results compared to other regimens. Postulation of removing toxic burden through paracentesis has not been confirmed.

Fluid and electrolyte management for the surgical patient

For surgical patients, appropriate selection and administration of fluids can mitigate against organ failure, whereas improper dosing can exacerbate already injured systems. Fluid and electrolyte goals and deficiencies must be defined for individual patients to provide the appropriate combination of resuscitation and maintenance fluids. Specific electrolyte abnormalities should be anticipated, identified, and corrected to optimize organ functions. Using the strong-ion approach to acid-base assessment, delivered fluids that contain calculated amounts of electrolytes will interact with the patient's plasma charge and influence the patient's pH, allowing the clinician to achieve a more precise end point.

[Ascites, hepatorenal syndrome and spontaneous bacterial peritonitis in patients with portal hypertension]

Ascites, hepatic encephalopathy and variceal hemorrhage are three major complications of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its etiology by determining the serum-ascites albumin gradient and the exclusion of spontaneous bacterial peritonitis. Ascites is primarily related to an inability to excrete an adequate amount of sodium into urine, leading to a positive sodium balance. Sodium restriction and diuretic therapy are keys of ascites control. But, with the case of refractory ascites, large volume paracentesis and transjugular portosystemic shunts are required. In hepatorenal syndrome, splanchnic vasodilatation with reduction in effective arterial volume causes intense renal vasoconstriction. Splanchnic and/or peripheral vasoconstrictors with albumin infusion, and renal replacement therapy are only bridging therapy. Liver transplantation is the only definitive modality of improving the long term prognosis.

Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis

BACKGROUND & AIMS

A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor.

METHODS

Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients).

RESULTS

Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005).

CONCLUSIONS

In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.

Current status of liver diseases in Korea: liver cirrhosis

Liver cirrhosis represents the final common pathway of virtually all chronic liver diseases, and is characterized by an accumulation of extracellular matrix rich in fibrillar collagens. Patients with cirrhosis are at risk of developing many potential complications. The most common complication seen in patients with liver cirrhosis is ascites, and the most lethal one is bleeding varices. Other intermediate and late stage complications include spontaneous bacterial peritonitis, hepatic encephalopathy, and hepatorenal syndrome. The mortality and morbidity attributable to liver disease in Korea have decreased continuously over the past decades, probably due to the implementation of universal vaccination and potent antiviral therapies. In addition, recent advances in the understanding of the pathophysiology of cirrhosis and in various management approaches to cirrhosis complications will contribute to the steady improvement in patient outcomes in this country. This review article outlines recent changes in etiologies and prognosis, and the advances in management of cirrhosis in Korea.

Ascites and spontaneous bacterial peritonitis: an Asian perspective

Ascites is the most common complication of liver cirrhosis, and it develops as a consequence of portal hypertension and splanchnic vasodilatation. Depending on severity, management of ascites consists of diverse strategy, including dietary sodium restriction, diuretic therapy, repeated large-volume paracentesis with albumin infusion, transjugular intrahepatic portosystemic shunt, and liver transplantation. Recently, advances in medical therapy have been made with satavaptan, a V2 receptor antagonist, vasoconstrictors, such as clonidine, midodrine, or terlipressin, and other categories of drugs, including docarpamine and Chinese herbs. These drugs may serve as useful adjuncts to conventional diuretics in the management of ascites. Besides ascites itself, serious complications, such as spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome, frequently ensue in decompensated cirrhosis. SBP develops from the translocation of bacteria from the intestine, and successful management with early diagnosis and treatment with proper prevention in patients of high risk is necessary. In summary, ascites is a starting point for more serious complications in liver cirrhosis. Although liver transplantation is the fundamental treatment, it is not always feasible, and consequently various means of treatment should be used. Further study, particularly in Asia where hepatitis B virus-related cirrhosis is predominant, is warranted to improve the clinical outcome.

Spontaneous bacterial peritonitis

Since its initial description in 1964, research has transformed spontaneous bacterial peritonitis (SBP) from a feared disease (with reported mortality of 90%) to a treatable complication of decompensated cirrhosis, albeit with steady prevalence and a high recurrence rate. Bacterial translocation, the key mechanism in the pathogenesis of SBP, is only possible because of the concurrent failure of defensive mechanisms in cirrhosis. Variants of SBP should be treated. Leucocyte esterase reagent strips have managed to shorten the ‘tap-to-shot’ time, while future studies should look into their combined use with ascitic fluid pH. Third generation cephalosporins are the antibiotic of choice because they have a number of advantages. Renal dysfunction has been shown to be an independent predictor of mortality in patients with SBP. Albumin is felt to reduce the risk of renal impairment by improving effective intravascular volume, and by helping to bind pro-inflammatory molecules. Following a single episode of SBP, patients should have long-term antibiotic prophylaxis and be considered for liver transplantation.

Management of sepsis in patients with liver failure

PURPOSE OF REVIEW

Sepsis constitutes the most common cause of death in the ICU. Liver dysfunction is manifested among previously normal subjects with sepsis but even more so in populations with preexisting liver disease. Managing these patients is more challenging. We will review recent literature in sepsis and liver disease, and their bedside application.

RECENT FINDINGS

At the cellular-chemical level, studies showed that platelet aggregation and neutrophil activation occur before and are independent of microcirculatory changes which are apparent in all animal septic models. At the clinical level, early goal-directed therapy, euglycemia, low tidal volume ventilation, and early and appropriately dosed renal replacement therapy among others are all tools to improve sepsis survival. Acknowledgement of liver disease as an immunocompromised host, and identification and treatment of complications can positively change the outcome of sepsis in liver disease.

SUMMARY

Much has been advanced in the field of sepsis management. Understanding the pathophysiology of liver dysfunction and decompensation of a diseased liver incites questions for future research. Early goal-directed therapy, lactate clearance, glycemic control, low volume ventilation strategies, nutrition, adrenal insufficiency, renal dysfunction, hepatorenal syndrome prevention and treatment are some of the issues in the management of sepsis, with or without liver disease, that are relevant in this review.