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ASCITES (TENSE) BENEFITS FROM LARGE VOLUME PARACENTESIS

Clinical Bottom Line:
  1. Daily large volume (4-6L) paracentesis with IV albumin (40g) is more effective than in-hospital diuretic therapy in the short-term elimination of tense ascites [1,2].
  2. Daily paracentesis with albumin may also be associated with less complications, shorter length of stay and lower short-term mortality then diuretic therapy [1,2].
  3. Large volume paracentesis with albumin does not induce significant changes in renal function, plasma volume or electrolytes [1,2].
Appraised by: D. Seib, HN Lee, November 19th 1992

The Evidence: [1,2] 2 RCT's. Patients with "tense" ascites failing outpatient diuretics and no acute illness or CA.

Study with outcomeDiureticsParacentesis RRRARR (95% CI)NNT / p
[1] Gines et al [1];
Ascites Elimination
Complications
Mortality (in hosp.)

Length of Stay

 -
43/59 = .73
36/59 = .61
13/59 = .22

31 +/- 2.8d

 -
56/58 = .97
10/58 = .17
4/58 = .07

11.7 +/- 1.5d

 -
.25
.72
.68

-

 -
.24 (.10 to .37)
.44 (.27 to .61)
.15 (.02 to .29)

-

 NNT
4
2.3
7

p <0.5

[2] Salerno et al [2];
Ascites Elimination

Mean Time to Elimination

 -
19/21 = .91

15d

 -
19/20 = .95

3.5d

 -
.04

-

 -
.04 (-.14 to .23)

-

 -
NS

P <0.05

Comments:

  1. Complications defined as hyponatremia, encephalopathy, renal impairment, hyperkalemia, GI bleeding, peritonitis and bacteremia.
  2. Large volume paracentesis is probably safer with than without albumin (IV 40g after paracentesis)[3].
  3. In [1], 3/59 patients with failure to respond to diuretics were subjected to a LeVeen shunt.
  4. A recent review of the literature is found in [4].

References:

  1. Gines et al. Paracentesis vs diuretics RCT. Gastroenterology. 1987;93:234-241.
  2. Salerno et al. Paracentesis vs diuretics RCT. J Hepatology. 1987;5:102-8.
  3. Gines et al. Paracentesis with and without albumin. Gastroenterology 1988;94:1493-1502.
  4. Kellerman PS, Linas SL. Paracentesis review. Ann Int Med 1990;112(12):899-891.

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