DEXTRAN 70 AND OTHER PLASMA EXPANDERS
The use of synthetic plasma expanders with large-volume paracentesis has also been
explored in patients with refractory ascites.
ascites refractory to diuretic therapy, who required paracentesis. More patients
treated with dextran 70 (34.4%) or polygeline (37.8%) experienced PICD than those
78 Hydroxyethyl starch, an effective colloid agent for
intravascular volume expansion, should not be used in patients with cirrhosis,
because repeated administration in this population has been reported to accumulate in
the hepatocytes, causing severe portal hypertension and acute liver failure.
R.W. should be given 50 g of 25% albumin administered at a rate of 3 mL/minute,
for the 6 L of ascitic fluid removed. Albumin 25% infusion is preferred because 5%
solution has fivefold the sodium load.
38 More rapid administration than 3 mL/minute
in hypoproteinemic patients can cause circulatory overload and pulmonary edema.
R.W. should be monitored for anaphylactic reactions (rare), hypotension,
hypertension, and signs of pulmonary edema.
CASE 25-1, QUESTION 11: What alternative treatments are available for management of refractory
ascites? How would these alternatives be applied in R.W.’s case?
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
Transjugular intrahepatic portosystemic shunt (TIPS) is another option for patients
who are refractory to the pharmacologic interventions described previously. It is a
nonsurgical technique for establishing a shunt in patients with portal hypertension
83 The TIPS procedure involves opening a conduit between the hepatic
vein and the intrahepatic segment of the portal vein with an expandable metal stent
placed during an angiographic procedure. This low-resistance channel allows blood
to return to the systemic circulation and reduces portal pressure. In addition, TIPS
may improve urinary sodium excretion. The major complications of TIPS include
severe encephalopathy and shunt occlusion. Hepatic encephalopathy (see Case 25-3)
occurs in approximately 20% of patients after TIPS.
liver transplantation should be considered for appropriate candidates refractory to
pharmacologic treatment and/or shunt placement.
38 Selection of surgical shunt
procedures may include evaluation of liver transplantation candidacy because some
procedures may complicate the feasibility of a future liver transplantation procedure.
In a small randomized study evaluating patients with cirrhosis and refractory
the probability of survival without liver transplantation was 41% at 1 year
and 26% at 2 years in the TIPS group, as compared with 35% and 30%, respectively,
in the paracentesis group (not significant [NS]). Recurrence of ascites and
development of hepatorenal syndrome (49% and 9%, respectively) were lower in the
TIPS group compared with the paracentesis group (83% and 31%, respectively; p =
0.003 and p = 0.03), whereas the frequency of severe hepatic encephalopathy was
greater in the TIPS group (p = 0.03). The calculated costs of procedures performed
per patient in the TIPS group were 103% greater than those in the paracentesis and
85 conducted a meta-analysis of cirrhotic patients with
refractory ascites and found that transplant-free survival was higher in the TIPS
group (38.1% vs. 28.7% at 3 years; p = 0.035), and the recurrence of ascites was
lower (42% vs. 89%; p < 0.0001) than in the large-volume paracentesis group. The
average number of hepatic encephalopathy episodes was significantly higher in the
TIPS group (p = 0.006). However, the probability of developing the first episode of
hepatic encephalopathy was similar between the groups (p = 0.19).
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