Oral midodrine is comparable to albumin infusion in cirrhotic patients with refractory ascites undergoing large-volume paracentesis: results of a pilot study

Abstract

Background and aims Albumin infusion reduces the incidence of postparacentesis circulatory dysfunction among patients with cirrhosis and tense ascites compared with no treatment. Less costly treatment alternatives such as vasoconstrictors have been investigated, but the results are controversial. Midodrine, an oral α1-adrenergic agonist, increases effective circulating blood volume and renal perfusion by increasing systemic and splanchnic blood pressure. Our aim is to assess whether or not morbidity in terms of renal dysfunction, hyponatremia, systemic, or portal hemodynamics derangement or mortality differed in patients receiving albumin versus midodrine. Patients and methods Seventy-five patients with cirrhosis and refractory ascites were randomized to receive albumin infusion, oral midodrine for 2 days, or oral midodrine for 30 days after therapeutic large volume paracentesis (LVP). The primary endpoints were development of renal impairment or hyponatremia, change in systemic and portal hemodynamics, cost, and mortality in the short-term and long-term follow-up. Results No significant difference was found between groups in the development of renal impairment, hyponatremia, or mortality 6 and 30 days after LVP. A significant increase in 24-h urine sodium excretion was noted in the midodrine 30-day group. Renal perfusion improved significantly with the midodrine intake for 30 days only. The cost of midodrine therapy was significantly lower than albumin. Conclusion Midodrine is as effective as albumin in reducing morbidity and mortality among patients with refractory ascites undergoing LVP at a significantly lower cost. Long-duration midodrine intake can be more useful than shorter duration intake in terms of improvement of renal perfusion and sodium excretion.

Prevention of paracentesis‐induced circulatory dysfunction—A systematic review and network meta‐analysis

“…One trial was multiarmed comparing albumin against Dextran 70 and polygeline 2 . Studies with no active comparator (or placebo) were excluded 23 . Three studies were excluded as they had not defined the primary outcome based on PRA 23‐25 .…”

“…Studies with no active comparator (or placebo) were excluded 23 . Three studies were excluded as they had not defined the primary outcome based on PRA 23‐25 . One study was excluded as they have not given the absolute value of PRA 26 .…”

HEP-Net opinion on the management of ascites and its complications in the setting of decompensated cirrhosis in the resource constrained environment of Pakistan

“…A combination of albumin with octreotide at a dose of 200 microgram subcutaneously three times a day and oral at a titrated dose of upto 12.5mg three times a day has been of benefit in a few studies from the US and Europe. 48,123 This combination was found to be superior to dopamine combined with albumin. 124 Noradrenaline at a dose of 0.5-3mg/h is infused continuously dose is gradually increased to achieve a raise in arterial blood pressure and improvement in renal parameters in HRS-AKI.…”

“…Long-duration midodrine intake can be more useful than shorter duration intake in terms of improvement of renal perfusion and sodium excretion. [48][49][50][51] Beta blockers have been proven to have a deleterious effect on survival in patients with refractory ascites and should be stopped. 52,53 Recommendations:…”

Midodrine in Liver Cirrhosis With Ascites: A Systematic Review and Meta-Analysis

“…Included studies are reference nos. [1,3,4,[6][7][8][14][15][16][17][18][19][20][21][22] Data Analysis…”