The First Study to Show the Need for Plasma Expanders During Paracentesis
The 1990 study by Ginés et al., published in Gastroenterology, was the first to demonstrate the need for plasma expanders during large-volume paracentesis in cirrhotic patients with ascites 1.
Historical Context and Key Findings
This landmark study randomized 88 cirrhotic patients with tense ascites to receive either albumin or dextran-70 (8g/L of ascitic fluid removed) following total paracentesis. The researchers found:
- Without plasma expansion, paracentesis led to significant decreases in effective intravascular volume
- Plasma renin activity and aldosterone concentration increased significantly by day 6 in patients receiving dextran-70 (51% of patients) compared to only 15% in the albumin group
- This demonstrated that albumin was superior to dextran-70 in preventing post-paracentesis circulatory dysfunction
Evolution of Evidence on Plasma Expanders
Following this initial study, subsequent research has further clarified the importance of plasma expansion:
- A 1996 study by Ginés et al. confirmed that post-paracentesis circulatory dysfunction is not spontaneously reversible and is associated with shorter survival and earlier readmission 2
- This study established albumin as superior to other plasma expanders (dextran-70 and polygeline) in preventing circulatory dysfunction
Current Guidelines on Plasma Expansion
Current guidelines from the European Association for the Study of the Liver (2021) recommend:
- For large-volume paracentesis (>5L), plasma expansion with albumin at 6-8g/L of ascites removed is recommended 3
- For paracentesis <5L, plasma expansion is generally not necessary unless there is evidence of acute-on-chronic liver failure 3
- Human albumin solution (HAS) is preferred over other plasma expanders due to availability, familiarity, and demonstrated benefits 3
Mechanism of Post-Paracentesis Circulatory Dysfunction
The 1985 study by Pinto et al. was among the first to investigate the hemodynamic effects of large-volume paracentesis, measuring plasma volume changes using 125I-labeled human serum albumin dilution technique 4. However, this study did not conclusively establish the need for plasma expanders.
Clinical Implications
- Albumin remains the gold standard for plasma expansion following large-volume paracentesis, with a recommended dose of 6-8g/L of ascites removed 5
- Alternative plasma expanders (hydroxyethyl starch, dextran) have been studied but are less effective and some carry additional risks 3, 5
- Ultrasound guidance during paracentesis reduces the risk of adverse events 3
Common Pitfalls to Avoid
- Failing to administer albumin after large-volume paracentesis (>5L) increases the risk of post-paracentesis circulatory dysfunction, renal impairment, and mortality
- Using alternative plasma expanders that are now restricted by regulatory agencies (e.g., polygeline, dextran, hydroxyethyl starch) due to safety concerns
- Overlooking the need for albumin in patients with acute-on-chronic liver failure, even with paracentesis <5L
The Ginés et al. 1990 study was pivotal in establishing the foundation for current paracentesis protocols and demonstrating the importance of plasma expansion to prevent circulatory dysfunction and associated complications.