Midodrine versus Albumin to Prevent Paracentesis Induced Circulatory Dysfunction in Acute on Chronic Liver Failure Patients in the Outpatient Clinic-a Randomized Controlled Trial

Jaya Sai N Sujith Reddy; Nitin Jagtap; Rakesh Kalpala; Anand Kulkarni; Rajesh Gupta; Padaki Nagaraja Rao; Sowmya Iyengar; Manasa Alla; Duvvur Nageshwar Reddy; Mithun Sharma

doi:10.1016/j.jceh.2023.01.009

Midodrine versus Albumin to Prevent Paracentesis Induced Circulatory Dysfunction in Acute on Chronic Liver Failure Patients in the Outpatient Clinic-a Randomized Controlled Trial

J Clin Exp Hepatol. 2023 Jul-Aug;13(4):576-585. doi: 10.1016/j.jceh.2023.01.009. Epub 2023 Jan 28.

Affiliations

¹ Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India.
² Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, India.
³ Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India.

PMID: 37440947
PMCID: PMC10333951 (available on 2024-07-01)
DOI: 10.1016/j.jceh.2023.01.009

Abstract

Background: Paracentesis-induced circulatory disturbance (PICD) occurs in 12-20% of patients receiving human albumin for large-volume paracentesis, and can occur at lower than five liter paracentesis in acute-on-chronic liver failure (ACLF). Albumin infusions are associated with higher costs and more prolonged daycare admissions. The aim of the study was to determine if oral midodrine-hydrochloride can prevent PICD in these patients by increasing the mean arterial pressure (MAP).

Methods: This open-labeled randomized controlled trial included ACLF patients undergoing paracentesis between 3 and 5 L, who were randomized to receive either 20% human albumin or midodrine hydrochloride 7.5 mg thrice daily for three days, 2 h before paracentesis. MAP was recorded daily. The primary outcome was the plasma renin activity (PRA) on day six, and a 50% increase from baseline was considered PICD.

Results: 183 consecutive patients of ACLF were screened, and 50 patients were randomized to either arms. Alcohol was the most common underlying cause of cirrhosis. On day 6, PRA was non-significantly (P = 0.056) higher in the midodrine group. The absolute change of PRA between the two groups was not significant (P = 0.093). Four (16%) patients in the albumin group and five (20%) in the midodrine group developed PICD. MAP increase was not different between the albumin and midodrine arms (P = 0.851). Midodrine was found to be more cost-effective.

Conclusions: Three days of oral midodrine is as effective as a human-albumin infusion in preventing PICD in ACLF patients undergoing paracentesis lesser than that done in large volume paracentesis.

Keywords: acute on chronic liver failure; midodrine hydrochloride; paracentesis; paracentesis-induced circulatory dysfunction; plasma renin activity.