Rifaximin and midodrine improve clinical outcome in refractory ascites including renal function, weight loss, and short-term survival.
OBJECTIVE
The occurrence of refractory ascites in nearly 17% of patients with decompensated cirrhosis is an unresolved issue. Advanced liver disease, functional renal impairment, and vascular insensitivity to vasopressors are the main causes of its refractoriness. Therefore, the aim of this study was to evaluate the impact on diuresis, weight loss, and short-term survival if midodrine and rifaximin were added to the diuretic therapy (DT).


METHODS
The study evaluated the eligibility of 650 patients with cirrhosis and refractory ascites who were selected during the period from November 2011 to May 2015. A total of 50 patients were excluded and finally 600 were selected and divided into the following groups: patients exposed to DT (n=200) as a control group, or DT with midodrine and rifaximin group (n=400). Body weight, mean arterial pressure, and glomerular filtration rate were determined. Plasma renin and aldosterone were also determined. Follow-up was performed after 2, 6, and 12 weeks, and then every 2 months for 24 months.


RESULTS
The mean arterial pressure was significantly higher in the midodrine and rifaximin group (P=0.000), and there was a highly significant weight loss after 12 weeks (12.5 kg) (P=0.000), a highly significant increase in serum sodium, urine output, and urinary sodium excretion (P=0.000), and creatinine clearance was more reduced in the control group. With rifaximin and midodrine, a complete response occurred in 310 (78%) patients, a partial response in 72 (18%), and no response in 18 (4%) versus 30 (15%), 110 (55%), and 60 (30%) in the control group, respectively (P=0.000). Midodrine and rifaximin significantly reduced paracentesis needs when compared with the controls (18 study patients vs. 75 DT-only patients, P=0.000).


CONCLUSIONS
Adding rifaximin and midodrine to DT enhanced diuresis in refractory ascites with improved systemic, renal hemodynamics and short-term survival.
aDepartment of Internal Medicine, Division of Hepatogatroenterology bDepartment of Clinical pathology, Zagazig University, Zagazig, Egypt cSulaiman Al Rajhi Colleges, Al Bukayriyah, Saudi Arabia.
Amr S
AS
Hanafy
Ahmad M
AM
Hassaneen
D000450:Aldosterone / Q000378:metabolism; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D001201:Ascites / Q000188:drug therapy* / Q000209:etiology / Q000378:metabolism / Q000503:physiopathology; D001794:Blood Pressure; D001835:Body Weight; D004232:Diuretics / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007668:Kidney / Q000378:metabolism / Q000503:physiopathology; D008103:Liver Cirrhosis / Q000150:complications; D008297:Male; D008875:Middle Aged; D008879:Midodrine / Q000627:therapeutic use*; D019152:Paracentesis / Q000706:statistics & numerical data; D012083:Renin / Q000378:metabolism; D012294:Rifamycins / Q000627:therapeutic use*; D000078262:Rifaximin; D016037:Single-Blind Method; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*
D000890:Anti-Infective Agents; D004232:Diuretics; D012294:Rifamycins; D014662:Vasoconstrictor Agents; D000450:Aldosterone; D008879:Midodrine; D012083:Renin; D000078262:Rifaximin