Prompt ascitic drain removal averts bacterial peritonitis, AKI in cirrhosis with refractory ascites

Ascitic drain removal (ADR) within 24 hours among cirrhosis patients with refractory ascites appears to lower the risk of ascitic drain-related bacterial peritonitis (AdBP) and acute kidney injury (AKI), according to a Singapore study.

“As AdBP is associated with more resistant organisms and a higher risk of AKI, prompt ADR within 24 hours is recommended, especially among alcoholic cirrhosis patients with Child-Pugh Class C or a higher Model for End-Stage Liver Disease (MELD) score,” the researchers said.

A total of 131 cirrhotics with refractory ascites (mean age 68.3±11.6 years, 65.6 percent male) who underwent large-volume paracentesis (LVP) at the Changi General Hospital, Singapore, from 2014 to 2017 were included in the study. The researchers diagnosed AdBP based on ascitic fluid neutrophil count ≥250 cells/mm3 or positive ascitic fluid culture following recent paracentesis within 2 weeks.

All participants were followed for 1,806 patient-months and had a mean MELD score of 15.2. The overall incidence of AdBP stood at 5.3 percent. [Singapore Med J 2021;doi:10.11622/smedj.2021049]

ADR beyond 24 hours significantly correlated with longer median length of stay (5 vs 3 days; p<0.001), higher risk of AdBP (0 percent vs 8.9 percent; p=0.042), and AKI following LVP (odds ratio, 20.0, 95 percent confidence interval, 2.4–164.2; p=0.021). Overall survival, however, was similar between patients with ADR within 24 hours and those with ADR beyond 24 hours.

“In practice, some physicians may choose to delay the timing of ADR for up to 48 hours, either to minimize paracentesis-induced circulatory dysfunction and AKI or to prioritize complete ascitic drainage over timing of ADR in hopes of reducing readmissions in patients with refractory ascites,” the researchers said. [Dig Dis Sci 2011;56:2723-2727]

“However, there is no substantial evidence that such practice is beneficial to patient care. While it is unlikely that a prospective study will be performed, these findings should serve as a reminder to clinicians that leaving a drain for longer durations increases the risk of AdBP and that there is no merit in protracted ascitic drainage,” they added.

AdBP, if not prevented, could increase the risk of AKI and prolong hospitalization, particularly among cirrhosis patients with higher MELD scores. Longer hospitalization could then increase the direct healthcare cost for patients and predispose them to an increased risk of nosocomial infections by multidrug-resistant organisms (MDRO), the researchers noted. [Singapore Med J 2020;61:419-425]

The emergence of MDRO in AdBP could affect survival of hospitalized cirrhotics and might increase the risk of acute-on-chronic liver failure (ACLF).

“It is now clear that ACLF carries a high 90-day mortality of 50.4–56.1 percent among hospitalized decompensated cirrhosis patients,” the researchers said. [Hepatology 2019;69:2150-2163; J Hepatol 2018;69:154-181]

“As a palliative procedure, the goal of LVP should be symptom relief rather than complete drainage of ascites. Our data supports prompt ADR within 24 hours to mitigate the risk of AdBP and AKI from LVP,” they added.