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.
BACKGROUND
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.


CONCLUSIONS
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.
Umgelter
Andreas
A
Medizinische Klinik und Poliklinik der Technischen Universität München, Ismaningerstrasse 22, 81675 München, Germany. andreas.umgelter@lrz.tu-muenchen.de
Reindl
Wolfgang
W
Wagner
Katrin S
KS
Franzen
Michael
M
Stock
Konrad
K
Schmid
Roland M
RM
Huber
Wolfgang
W
D000418:Albumins / Q000008:administration & dosage / Q000627:therapeutic use*; D001201:Ascites / Q000150:complications / Q000628:therapy*; D001810:Blood Volume; D003404:Creatinine / Q000097:blood; D005260:Female; D006439:Hemodynamics; D006530:Hepatorenal Syndrome / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications* / Q000209:etiology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D019152:Paracentesis; D011446:Prospective Studies
D000418:Albumins; D003404:Creatinine