Prevention of paracentesis-induced circulatory dysfunction: could we use other albumin alternatives? Ayman Alsebaey a , Wael Abdel-Razek a , Ashraf Bassuni b , Eman Rewisha a , Magdy Khalil c and Imam Waked a Departments of a Hepatology, b Clinical Biochemistry and c Anesthesia and ICU, National Liver Institute, Menoufiya University, Shebeen El-Kom, Egypt Correspondence to Ayman Alsebaey, MD, Department of Hepatology, National Liver Institute, Menoufiya University, 32511 Shebeen El-Kom, Egypt Tel: + 201003751248; fax: + 20 482 234 586; e-mail: asebaey@liver-eg.org Received 18 February 2013 Accepted 13 May 2013 Egyptian Liver Journal 2013, 3:118–125 Background Ascites is a severe complication of cirrhosis. Large-volume paracentesis (LVP) is used to treat large or refractory ascites. LVP without volume expansion by albumin leads to paracentesis-induced circulatory dysfunction (PICD). Aim This study aimed to compare terlipressin, hydroxyethyl starch (HES), midodrine, and low-dose albumin with standard-dose albumin in the prevention of PICD following LVP. Patients and methods A total of 125 patients (69 men, mean age 50.33 ± 7.74 years, 113 with HCV cirrhosis) with tense ascites treated with LVP were randomized to receive either intravenous terlipressin (3 mg), intravenous HES (8 g/l removed), oral midodrine (5–10 mg three times daily), low-dose albumin (2 g/l removed), or standard-dose albumin (6 g/l removed). Plasma renin activity (PRA) was assessed at baseline and on day 6. PICD was defined as an increase in PRA of greater than 50% of the pretreatment value. Results The volume removed was 13 ± 0.14 l/patient and was not different between groups (P40.05). PRA increased insignificantly by 8% with HES (P = 0.29) and significantly by 16–20% (Po0.05) in the other groups. PICD occurred equally with terlipressin (2, 8%), HES (2, 8%), low-dose albumin (3, 12%), and standard-dose albumin (3, 12%), and insignificantly more with midodrine (5, 20%) (P40.05). In all groups, urine output at discharge was significantly larger than baseline but did not differ among groups. Drug cost was significantly less in all groups compared with standard albumin ($275), terlipressin $100, HES $38.5, midodrine $0.8, and low-dose albumin $103 (Po0.05). Conclusion Terlipressin, HES, and low-dose albumin are equally effective and less costly substitutes for albumin in preventing PICD following LVP. Keywords: albumin, ascites, large-volume paracentesis, paracentesis-induced circulatory dysfunction Egypt Liver J 3:118–125 & 2013 Egyptian Liver Journal 2090-6218 Introduction Ascites is a common complication of cirrhosis that is associated with both poor quality of life and long-term outcome [1–3]. Therapeutic paracentesis is used in patients with cirrhosis and tense ascites. After large-volume para- centesis (LVP) of more than 5 l, intravenous administration of plasma expanders is indicated to prevent paracentesis- induced circulatory dysfunction (PICD) [1,4,5]. PICD is characterized by a reduction of effective arterial blood volume with subsequent activation of vasoconstric- tor and antinatriuretic factors. This ultimately causes high recurrence rate of ascites, development of hepato- renal syndrome and/or dilutional hyponatremia in 20% of cases, and increased mortality [6]. When less than 5 l of ascites are removed, PICD usually does not occur, and artificial plasma expanders, saline, and albumin are equally effective [7]. However, if more than 5 l is removed, albumin is recommended at a dose of 6–8 g/l ascites removed [4–7]. Albumin probably has other important functions in addition to being a plasma expander, such as ligand binding, antioxidant, free radical scavenging, and possibly anti- inflammatory [8–10]. Preventing PICD with albumin has been a subject of controversy since the initial studies were published in the late 1980s. This is mainly because of the fact that despite albumin’s greater efficacy in preventing PICD, random- ized comparative studies have not shown differences in the survival of patients treated with albumin compared with those treated without albumin or with other plasma expanders [11]. In addition, albumin is costly, and being a blood product, may have an inherent risk of transmission of diseases. 118 Original article 2090-6218 & 2013 Egyptian Liver Journal DOI: 10.1097/01.ELX.0000433597.15423.45 Copyright © Egyptian Liver Journal. Unauthorized reproduction of this article is prohibited.