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Internal Medicine

Paracentesis-induced circulatory dysfunction (PICD)

Serious complication of large volume paracentesis (LVP) without a plasma expander that leads to faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival.

Serious complication of large volume paracentesis (LVP) without a plasma expander that leads to faster reaccumulation of ascites, hyponatremia, renal impairment, and shorter survival.

  • Clinical definition: 50% increase in the plasma renin activity (PRA) over the baseline on the 6th day after treatment, up to a value > 4 ng/mL per hour

Pathophysiology

Decreased systemic vascular resistance:

LVP causes mechanical decompression of the splanchnic vascular bed leading to splanchnic vasodilation, a further decrease in the arterial filling, and activation of neurohormonal systems.

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. This results in free water and sodium retention. As a consequence, patients develop rapid reaccumulation of ascites, hyponatremia, renal injury, and encephalopathy.

Mechanism of PICD and complications. | Kulkarni, A. V., Kumar, P., Sharma, M., Sowmya, T. R., Talukdar, R., Rao, P. N., & Reddy, D. N. (2020). Pathophysiology and Prevention of Paracentesis-induced Circulatory Dysfunction: A Concise Review. Journal of clinical and translational hepatology, 8(1), 42–48. https://doi.org/10.14218/JCTH.2019.00048

Clinical features

PICD is a clinically silent syndrome, but an independent predictor of mortality in patients with massive ascites treated with large-volume paracentesis.

Re-emergence of symptoms:

Patients with PICD reaccumulate ascites and experience a return of symptoms more rapidly after paracentesis
  • Rapid re-accumulation of ascites
  • Dilutional hyponatremia
  • Hepatorenal syndrome
  • Decreased survival

Management

Plasma volume expanders:

Volume expansion with albumin infusion is the mainstay of treatment.
  • Human albumin infusion (best option due to long half-life of 21 days and additional actions as an antioxidant, detoxification, immunoprotective, drug binding and delivery properties)
  • Midodrine 1-agonist): Acts on the α-adrenergic receptors of arteriolar and venous vasculature, producing an increase in vascular tone and elevation of blood pressure.
  • Noradrenaline (potent α-agonist): Global vasoconstriction
Drugs used for the prevention of the paracentesis-induced circulatory dysfunction | Alsebaey, A., Rewisha, E. & Waked, I. Paracentesis-induced circulatory dysfunction: are there albumin alternatives?. Egypt Liver Journal 10, 39 (2020). https://doi.org/10.1186/s43066-020-00047-7

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