Large volume paracentesis: Is there a limit?

Abstract

Introduction and Objectives

Ascites is observed in 5-10% of cirrhotic patients. Large volume paracentesis (LVP), where >5 liters are drained, is safe. Albumin is essential to prevent post-paracentesis circulatory dysfunction (PPCD), with the literature indicating that its incidence increases when draining >8 liters in one session, suggesting draining a smaller amount.

Materials and Patients

An observational, analytical, and retrospective study was conducted, which included the clinical records of patients over 18 years of age admitted to the Gastroenterology service of the General Hospital of Mexico "Dr. Eduardo Liceaga" from January 2020 to March 2024 with a diagnosis of Grade II or III ascites, without criteria for acute kidney injury (AKI) according to the International Ascites Club (ICA) and with baseline creatinine available in the last 3 months before assessment. The amount of ascites that were drained was evaluated, with no limit of liters in a session, and the occurrence of AKI during the following 7 days after paracentesis as a manifestation of PPCD. The definition of AKI was according to the latest definition by KDIGO / ICA. We excluded patients admitted with a diagnosis of AKI or a history of chronic kidney disease (CKD) of any etiology, and those in whom it was not specified whether albumin was administered after paracentesis. Descriptive statistics were performed with measures of central tendency and dispersion. We used X2, Student's T test, and Mann-Whitney U test to compare the variables. A value of P < 0.05 was considered statistically significant.

Results

We included 60 patients with a diagnosis of cirrhosis, administered for grade II and grade III ascites, 53.3% were men, with an overall mean age of 51.1 ±10.5 years. Regarding the etiology, 45% were due to alcohol, 21.7% to Fatty Liver Disease Associated with Metabolic Dysfunction (MASLD), as well as the etiology of no filiation; with MELD-Na 17.5 ± 5.7 points. Regarding ascites, 26.7% were grade II and 73.3% grade III, and up to 10% with refractory ascites. The average of liters of ascites drained per session was 8.5 ± 3.8 liters, with a minimum drainage of 5 liters and a maximum of 19.4 liters per session. Of the total patients evaluated, 5% (3) developed AKI after paracentesis, with an elevation of creatinine > 0.3 mg/dl in 48 hours. When comparing groups regarding the presence of ACLF, Child-Pugh, or MELD-Na; Regarding the DPPC, 41.66% (0%) drained less than 8 liters vs 58.34% (8.57%) more than 8 liters, all with refractory ascites, with no significant difference in the development of AKI (p=>0.05).

Conclusions

LVP is safe as long as the albumin dose is adequately replaced at a dose of 6-8 grams per liter of drained ascites in a single session, with caution in patients with refractory ascites, due to the advanced stage of portal hypertension.