What we know about paracentesis induced circulatory dysfunction?

Ascites is the most common complication in liver cirrhosis (LC), occurring in 60% of the patients with compensated LC within 10 years. Therapeutic paracentesis is an effective treatment for tension-type ascites, because it relieves the symptom more quickly than diuretics and shortens hospitalization. Refractory ascites is defined as fluid overload that is not controlled despite restriction of sodium intake and the maximum dose of diuretics, and recurs rapidly after paracentesis. Large volume paracentesis (LVP) has become the first line of treatment for patients with severe and refractory ascites. Paracentesis-induced circulatory dysfunction (PICD) occurs as a complication of LVP. Though PICD remains clinically silent, it is an important predictor of mortality in patients with severe ascites treated by LVP. A recent meta-analysis concluded that PICD is associated with a high rate of ascites recurrence, development of hepatorenal syndrome, dilutional hyponatremia, and high mortality. PICD is definitively diagnosed through laboratory results, with increases of more than 50% of baseline plasma rennin activity to > 4 ng/mL/h on the 5 to 6 days after paracentesis. The exact pathophysiology of PICD is not entirely understood. PICD was initially thought to occur secondary to fluid shifting after paracentesis, resulting in decreased circulating volume. Additional studies demonstrated that decreased systemic vascular resistance also plays an essential role in PICD. The resulting effective hypovolemia due to arteriolar vasodilation in turn leads to a prolonged activation of the sympathetic nervous system and the rennin-angiotensin-aldosterone pathway. Increased plasma rennin activity in particular is characteristic of PICD, however general hyporesponsiveness to vasoconstrictors in the setting of cirrhosis decreases the ability to compensate for the accentuated vasodilation. One of the simplest ways to prevent PICD is to limit the volume of fluid removed to 5 to 6 L at a time. The incidence of PICD approaches 80% when a LVP is performed without additional therapeutic management; the incidence is reduced to 15 to 35% when volume expanders are used. Of all the plasma expanders, human albumin infusion is considered as the best option due to its long half-life of 21 days. In addition to its oncotic value, albumin has antioxidant, detoxification, immunoprotective, drug binding and delivery properties. One recent meta-analysis concluded that albumin was superior to other volume expanders and alternative treatments in decreasing the risk of PICD, hyponatremia, and mortality. A separate recent meta-analysis demonstrated the benSee Article on Page 365 What we know about paracentesis induced circulatory dysfunction?