The International Ascites Club defined “refractory ascites” as ascites that can’t be mobilized or the recurrence of which can’t be satisfactory prevented by medical therapy. Arroyo, et al. Hepatology 23:164-176, 1996.

Mobilization of Ascites defined as a decrease of ascites at least to grade 1. (1:mild, 2:moderate, 3:massive or tense), early recurrence is defined as the reappearance of grade 2 or 3 ascites within 4 weeks of initial mobilization.

Two subgroups defined:

  1. Diuretic-resistance ascites: ascites that can’t be mobilized or the early recurrence of which can’t be prevented due to a lack of response to dietary sodium restriction and intensive diuretic treatment (e.g. 400mg of spironolactone or 30mg of amiloride plus up to 160mg of furosemide daily).

  2. Diuretic Intractable Ascites that can’t be mobilized or the early recurrence of which can’t be prevented due to the development of diuretic-induced complication that preclude the use of an effective diuretic dosage.

Refractory Ascites occurs in approximately 5-10% of all cases of Ascites and is associated with poor prognosis:

Four therapeutic approaches are currently used for the treatment of Refractory Ascites

  1. Large volume paracentesis with or without volume substitution

  2. Peritoneovenous shunt (PVS)

  3. Transjugular intrahepatic portosystemic stent shunt (TIPS)

  4. Orthotopic liver transplantation (OLTX)

The widely available therapeutic approach is (LVP) .

Large-volume (LVP) or total paracentesis is safe and effective if volume expansion is performed after tapping large amount of ascites. Effective hypovelemia was suggested to be due to increased arterial compliance rather than decrease of circulating blood volume Vila et al. J Hepatol 1999, 28: 6399-45.

To prevent post-paracentesis effective hypovolimia:

Until now the most employed method is to associate the infusion with a plasma expand. When the volume of ascites is less than 5 liters the use of synthetic expanders such as dextrose 70 or Hemaccel is as effective as albumin. But if the volume of ascites exceed 5 liters albumin is more effective than synthetic plasma expander.

Dose of albumin: 8 grams for any liter of tapped fluid. Time of infusion: matter of debate-at the beginning-at the end-some hours after the end.

 

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AASLD Annual Liver Meeting, Dallas, TX 2001

 

This year’s the 52nd Annual meeting of the American Association for the Study of Liver Diseases (AASLD) was held in Dallas, Texas, from November 9 to 13 presenting groundbreaking research and new clinical treatments. There were more than 4.000 researchers from around 55 countries. Over half of attendees were from outside of the USA. This years’s Liver Meeting included research on different topics such as stem cell research, non-alcoholic steatohepatitis (NASH), and viral hepatitis. Presentations from Egypt featured the antischistosomal effect of praziquantel in hepatic cirrhosis by Dr Saleh M. Saleh. The other study had been presented by Dr. Mahmoud M. Omar. It demonstrates the value of insulin like growth factor as prognostic marker HCV-induced cirrhosis as it is significantly decreased in modified Child grade B and C patients.

 

A third study demonstrated that acute rejection (ACR) is dramatically less frequent in living-related right lobe recipients than in cadaveric or non-related receipients. A descreased rate of organ rejection in pediatric living donor liver transplant (LDLT) recipients has been reported, promoting researchers to study the rejection rate in adult recipients. Researchers found that, of the three groups that were established for the study, 64% of the living-related LDLT recipients, 44% of the non-related LDLT recipients and 17% of the cadaveric recipients did not have ACR. The findings of this study will prompt the  examination and possibly the adjustment of the protocols for administering immunosuppression. This is especially important to patients with hepatitis C. Reducing the types and dosage of immunosuppression and the ability to withdraw patients from immunosuppression at an earlier stage benefits patients with hepatitis C because immunosuppression actually makes the virus more aggressive.

 

As regards HCV, it has been shown during the symposium on ‘pegylated interferons in Hepatitis C: Treatment Outcoms’ that histologic endpoints are becoming more important, particularly in the nonrespoders to IFN therapy may prevent fibrosis progression and thus prevent cirrhosis and portal hypertension complications. The utilization of pegylated interferons has increased the response rates in previously nonresponding populations as African Americans. In addition, peginterferon alpha-2a (40KD) has also improved sustained virological response in those with HCV genotype 4 and in patients having recurrent HCV following OLT.

 


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