There is limited prospective data on nephrogenic ascites from. Management of adult patients with ascites due to cirrhosis. Ascites presentation free download as powerpoint presentation. Nephrogenic ascites associated with maintenance haemodialysis ccf, congestive cardiac failure. Ascites is a pathological accumulation of fluid in the peritoneal cavity. Morbidity and eventual mortality from this ongoing problem are significant. The sensitivity of these maneuvers is limited by the amount of peritoneal fluid present, and ultrasound is useful in defining small amounts of fluid. This is a temporary file and hence do not link it from a website, instead link the url of this page if you wish to link the pdf file. Neither the exact cause nor the pathogenesis of ascites formation is clearly understood.
It was used in diagnosis and to confirm the diagnosis in ascites of unknown origin which could be cirrhotic or non cirrhotic as carcinoma peritoneie, tuberculous peritonitis or nephrogenic origin. Ascites should be treated with salt restriction and diuretics. Contributing mechanisms may include fluid overload, peritoneal membrane changes not necessarily related to peritoneal dialysis, hypoproteinemia, and lymphatic drainage disturbances. Ascites may be detectable when more than 500 ml of fluid has accumulated. He had type 2 diabetes mellitus, coronary artery disease, hypertension, hyperlipidemia, and endstage renal disease esrd. Nephrogenic ascites is a condition characterized by the presence of massive ascites in a patient. Cirrhosis is the most common cause of ascites, representing for 85% of cases. Whereas some patients with ascites have peritoneal fluid pmn counts 250 cellsml, all patients with sbp do. The patient refused to restart peritoneal dialysis or to have a renal transplant. The most useful parameter for classifying ascites is the serum ascites albumin gradient saag. Strict volume control in the treatment of nephrogenic ascites. Laparoscopy has a valuable roles in diagnosis, preoperative assessment, and therapy of ascites. Nephrogenic ascites is a rare condition with a grave prognosis and an unknown but probably multifactorial cause.
Nephrogenic ascites jama internal medicine jama network. Aasld practice guideline management of adult patients with ascites due to cirrhosis. Assessment for ascites physicians should be familiar with the signs of ascites and physical examination maneuvers that can be used to detect ascites. A specially devised pressuresensitive valve forms the basis for a new peritoneovenous shunt operation which delivers ascitic fluid continuously into the venous system. Nephrogenic ascites or ascites associated with renal failure is seen in endstage renal disease inpatients on hemodialysis but has been described occasionally in earlier stages of renal failure. Development of ascites is a poor prognostic event in the natural history of cirrhosis, with approximately 15 and 44% of patients with ascites succumbing in. Diagnostic paracentesis was done and found to be exudative with serum ascites albumin gradient saag of 0. Download pdf nephrogenic ascites still an intractable problem. A 64yearold man was referred to a hepatology clinic for evaluation of ascites.
Nephrogenicascites can be cured by strict salt restriction, effective dialysis and persistent ultrafiltration in contrary to general belief. The term nephrogenic ascites is preferred as the onset of ascites may occur earlier in the course of renal failure and well before the initiation of dialysis. The diagnosis of nephrogenic ascites must be established by exclusion. Five of six patients with chronic renal failure and ascites have been maintained with, or are presently undergoing, intermittent hemodialysis. The patient was treated by cauterization of the majority of the surface of the allograft, which lead to an involution of the lesions and finally resolution of ascites formation. Nephrogenic ascites is a complex problem with a poorly understood pathophysiology. After detailed workup, hepatic, cardiac, infectious and malignant causes for ascites were ruled out. There are numerous causes of ascites, but the most common cause of ascites in the united states is cirrhosis, which accounts for approximately 80 percent of cases table 1 4.
Ascites due to right atrial myxoma in a haemodialysis. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a pdf plugin installed and enabled in your browser. Chylous ascites pancreatic ascites bile ascites nephrogenic ascites urine ascites ovarian disease causes diseased peritoneum. Nephrogenic ascites 1174 volumes numbers 1994 tients with esrd without aclear cause 1. Assessment for ascites centers for disease control and. Up to 19 percent of patients with cirrhosis will have hemorrhagic ascites, which may develop spontaneously 72 percent probably due to bloody lymph and percent. The condition may be accompanied by general abdominal swelling, hemodilution, edema, or a decrease in urinary output. The history usually is one of increasing abdominal girth, with the presence of abdominal pain depending on the cause. The diagnosis of ascites of nephrogenic origin was made. Because most ascites is secondary to chronic liver disease with portal hypertension, patients should be asked about risk factors for liver disease, especially alcohol consumption, transfusions, tattoos, injection drug use, a history of viral hepatitis or jaundice, and birth in. Peritoneal dialysis has been shown to resolve ascites, however, the only effective treatment is so far renal transplantation. This edition of the acr manual on contrast media replaces all earlier editions. The cause can be multifactorial and a combination of inadequate dialysis and ultrafiltration. Robert craig, marshall sparberg, peter ivanovich, laverne rice, erl dordal corresponding author for this work.
The protein content and lactic acid dehydrogenase level of the ascitic fluid in all patients with high, unlike the situation in patients with ascites of uncomplicated cirrhosis. There is limited prospective data on nephrogenic ascites from the indian subcontinent. Further experience with peritoneovenous shunt for ascites. Once ascites develops, patients should be referred for consideration of liver transplantation. Intractable ascites associated with mycophenolate in a.
Normally, a few millileters of fluid with a composition similar to that of the interstitial space is present between the visceral and parietal serous membrane of the peritoneal space 25. Other causes for ascites were ruled out in each case by peritoneoscopy, peritoneal fluid studies, and clinical data. It is being published as a webbased document only so it can be updated as frequently as needed. Ascites associated with endstage renal disease american. Chylous ascites pancreatic ascites bile ascites nephrogenic ascites urine ascites ovarian ascites myxoedema causes contd.
Nephrogenic ascites is described as a clinical condition of refractory ascites in patients with endstage renal disease esrd on. Conclusion features of nephrogenic ascites or congestive cardiac failure in a patient on renal replacement treatment who is adequately dialysed. This manual was developed by the acr committee on drugs and contrast media of the acr commission on. The procedure is simple and brings a long lasting relief with recovery in strength and nutrition. We report the case of a patient with nephrogenic ascites and concomitant secondary hyperparathyroidism who was resistant to the usual treatment but had a complete resolution after subtotal parathyroidectomy. Development of refractory ascites during amiodarone. Assessment of the patient with ascites current medical.
Ascites is a pathophysiological condition with increased fluid in the intraperitoneal space. Nephrogenic ascites is a clinical entity that manifests as refractory and exsudative ascites with unknown etiology in patients with end stage renal disease and often undergoing hemodialysis. Patients frequently present with hypertension, moderate to massive ascites, minimal extremity edema, cachexia, and a history of dialysisassociated hypotension. Update 2012 2012 the american association for the study of liver diseases, all. Nephrogenic ascites is a condition characterized by the presence of massive ascites in a patient with esrd. More than one cause may be responsible for the development of ascites multifactorial. Generally, the onset of nephrogenic ascites is insidious and portends a grim long term prognosis. Nephrogenic ascites is an entity that manifests as refractory ascites in patients with endstage renal disease, where portal hypertensive, infectious, and malignant. Pdf nephrogenic ascites still an intractable problem. Nephrogenic ascites is a complex diagnostic problem with poorly understood pathophysiology. Identification of ascites is made through palpation, percussion, and auscultation. History and physical examination in the united states, in approximately 85% of patients with ascites, cirrhosis is the cause, but 15% have a non. Sle, systemic lupus erythematosis table 3 main causes of malignant ascites note that peritoneal carcinomatosis accounts for twothirds of patients with malignancyrelated ascites histological type of malignancy %of total origin. We describe herein three patients who presented with refractory.
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