Slow, continuous low-dose albumin and furosemide infusion (SCLAFI) with/without terlipressinmobilizes refractory ascites safely in decompensated liver cirrhosis

Background and Aim: Graded increase of oral diuret ics has been the standard therapy for mobilizing large ascites in decompensated liver cirrhosis. Large volume paracentesis (LVP) with or without albumin infusions has been the commonest rescue therapy. Both are sought with complications. The study was done to study the efficacy and safety of low-dose, continuous, infusion of furosemide with albumin, administered according to a response-guided protocol in patients with cirrhosis and large ascites. Methods: Cirrhotic patients with refractory ascites (intractable/resistant) who had undergone multiple ses sions of large volume paracentesis in past 3 months were enrolled. Furosemide infusion at 2mg/h and albumin 2g/h (20g/d) was started. Blood and urine (electrolytes) samples were collected every 12h for UNa, UK and graded increase of furosemide was done by 1mg (max5mg/h) if UNa<80mmol/L. Aggressive potassiumsupplementation (oral/iv) was done in all patients. If after 48h UNa was still <80mmol/l then terlipressin infusion @4mg/12h was started after correcting anemia and baseline ECG (repeated 12th hourly) and response guided increase (1mg/12th hourly) was done (maximum 8mg/24h). Patients were shifted to oral diuretics at discharge main taining UNa >80mmol/24h. Results: 70 patients (M:F-50:20) were enrolled from November 2013 and July 2016. 57 patients had diuretic intractable ascites and 13 had diuretic resistant ascites. 19 patients required albumin-furosemide infusion only while 51 required terlipressin infusion also. Ascites responded (clinically dry) to the treatment regimen in all patients over a median period of 7.4±2.5 days. The mean val ues of the patient were: age 47.2±13.4, CTP 11.68±1.36, MELD 24.5±6.7, creatinine at baseline (bl) 1.42±1.05, creatinine at end of treatment (EOT) 0.94±0.43, serum sodium (SNa) (bl) 129.28±7.5, SNa (EOT) 133.96±5.45, weight loss 14.44 kg, UNa (bl) 17.2±5.86, maximum (max) UNa 171.24±61.35, UNa at discharge 86.4±19.56, serum albumin (bl) 2.5±0.5, urine output (UO) (bl) 642.7±185.3, UO (max) 2972.08±803.6. Conclusion: Closely monitored, response-guided use of frusemide infusion with albumin±terlipressin is a safe and effective way of treating large ascites reducing the need for LVP (Figure 1 and Table 1). (Table Presented).