Elsevier

Journal of Hepatology

Volume 26, Issue 3, March 1997, Pages 614-620
Journal of Hepatology

Diuretic requirements after therapeutic paracentesis in non-azotemic patients with cirrhosis. A randomized double-blind trials of spironolactone versus placebo

https://doi.org/10.1016/S0168-8278(97)80427-8Get rights and content

Abstract

Background/Aims: Diuretic requirements after mobilization of ascites by paracentesis have never been assessed in cirrhosis. It is also unknown whether diuretics increase the incidence of postparacentesis circulatory dysfunction. The aim of this study was to investigate these featurres and to assess whether measurement of plasma renin activity and aldosterone prior to paracentesis predicts diuretic response after this procedure.

Methods: Thirty-six patients with non-azotemic cirrhosis and ascites treated by total paracentesis plus i.v. albumin were randomly assigned to receive placebo (n=17) or spironolactone 225 mg/day (n=19) immediately after paracentesis and followed-up for 4 weeks.

Results: Five patients (three in the placebo and two in the spironolactone group) abandoned the treatment prior to ascites recurrence or the end of the study due to complications or lack of compliance. The analysis was performed in the remaining 31 patients. Ascites recurrence was more common in the placebo group (13 cases, 93%) than in the spironolactone group (3 cases, 18%) (p<0.0001) and occurred within the first 2 weeks of follow-up in more than 50% of patients. Patients developing ascites in the spironolactone group had higher levels of renin (14.1, 20.6, 32.4 ng/ml per h) and aldosterone (120, 149,288 ng/dl) than those who did not develop ascites renin: 2.0±2.1 ng/ml per h; range 0.1–6.8; aldosterone: 43±38 ng/dl; range 4–116). Three patients in the placebo group and two in the spironolactone group developed postparacentesis circulatory dysfunction (defined as an increase in renin at the third day after paracentesis greater than 50% over baseline levels up to a value higher than 4 ng/ml per h).

Conclusions: Patients with cirrhosis treated by paracentesis should receive diuretics immediately after this procedure to prevent early recurrence of ascites. The administration of 225 mg/day of spironolactone is a good empiric treatment for non-azotenic patients with cirrhosis, because it is effective in most cases and does not increase the incidence of postparacentesis circulatory dysfunction. The determination of plasma levels of renin or aldosterone prior to paracentesis predicts the efficacy of spironolactone in the prevention of ascites recurrence.

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    Citation Excerpt :

    Although paracentesis is the first-choice treatment of massive ascites, moderate ascites should be treated with salt restriction and diuretics to create a negative sodium balance.40,41 Diuretics also are required to prevent or delay further paracentesis in patients with massive ascites.42 Because renal perfusion and GFR are preserved in the early stages of ascitic decompensation, secondary hyperaldosteronism is the principal pathogenetic factor, and sodium retention mainly occurs at the distal nephron.43

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